Conservative management of persistent postnatal urinary and faecal incontinence: randomised controlled trial

OBJECTIVES

To assess the effect of nurse assessment with reinforcement of pelvic floor muscle training exercises and bladder training compared with standard management among women with persistent incontinence three months postnatally.

DESIGN

Randomised controlled trial with nine months' follow up.

SETTING

Community intervention in three centres (Dunedin, New Zealand; Birmingham; Aberdeen).

PARTICIPANTS

747 women with urinary incontinence three months postnatally, allocated at random to intervention (371) or control (376) groups.

INTERVENTION

Assessment by nurses of urinary incontinence with conservative advice on pelvic floor exercises at five, seven, and nine months after delivery supplemented with bladder training if appropriate at seven and nine months.

MAIN OUTCOME MEASURES

Primary: persistence and severity of urinary incontinence 12 months after delivery. Secondary: performance of pelvic floor exercises, change in coexisting faecal incontinence, wellbeing, anxiety, and depression.

RESULTS

Women in the intervention group had significantly less urinary incontinence: 167/279 (59.9%) v 169/245 (69.0%), difference 9.1% (95% confidence interval 1.0% to 17.3%, P=0.037) for any incontinence and 55/279 (19.7%) v 78/245 (31.8%), difference 12.1% (4.7% to 19.6%, P=0.002) for severe incontinence. Faecal incontinence was also less common: 12/273 (4.4%) v 25/237 (10.5%), difference 6.1% (1.6% to 10.8%, P=0.012). At 12 months women in the intervention group were more likely to be performing pelvic floor exercises (218/278 (79%) v 118/244 (48%), P<0.001).

CONCLUSIONS

A third of women may have some urinary incontinence three months after childbirth. Conservative management provided by nurses seems to reduce the likelihood of urinary and coexisting faecal incontinence persisting 12 months postpartum. Further trials for faecal incontinence are needed.

Perceived Stress and Support of the Chinese Postpartum Ritual “Doing the Month”

"Doing the month" is the traditional ritual for Chinese postpartum women. A qualitative study involving in-depth interviews with 20 Hong Kong Chinese women was conducted to examine the women's perceptions of stress and support in "doing the month." Four central themes were identified as follows: bound by the environmental constraints, difficulties in following the prescriptions of the rituals, conflicts between the parties involved, and attainment of the maternal role. The study revealed that "doing the month" is not necessarily protective and supportive of the postpartum women. It raises the critical question of how women can adapt the ritual to fit modern life. The study findings suggest that midwives and health care providers should provide culturally appropriate advice for new mothers. Suggestions are given on bridging the gap between traditional and modern postpartum practices.

Fatigue in postpartum women

Childbirth and the responsibilities of parenting after birth require a great deal of energy. Fatigue in postpartum women is a concern for maternal-child nurses because of the impact on the health and parenting ability of the mother. To determine fatigue levels and types, 35 women who vaginally delivered were surveyed at 2 days, 2 weeks, and 6 weeks postpartum. This sample was found to be mildly fatigued, with situational and/or psychological fatigue. Nurses can intervene by assessing postpartum fatigue and using teaching/counseling methods for knowledge preparation and for clients at risk.

Infant temperament and postpartum depression: a review

Although limited in number, reported research studies indicate a relationship between maternal perceptions of infant temperament and postpartum depression. Excessive crying in particular and the extent of adaptability and predictability have been implicated as infant behavioral indices. In this article, we present the results of a review of the literature linking early infant temperament to postpartum depression. Measurement issues for both infant temperament and depression are discussed. Recommendations for future research are offered.

The occurrence of breast engorgement

This study describes breast engorgement during days 1-14 postpartum of 114 first and second time vaginal- and cesarean-delivery breastfeeding mothers. Most mothers reported experiencing their most intense engorgement after hospital discharge. Previous breastfeeding experience of the mother is a more critical variable than parity in predicting engorgement. Second time breastfeeding mothers experienced engorgement sooner and more severely than did first time breastfeeding mothers, regardless of delivery method. Anticipatory guidance by the care provider is discussed in an effort to enhance the experience of the breastfeeding dyad.

Understanding postnatal depression: a mother-centred approach

Research findings on the causes and correlates of postnatal depression divide into two explanatory frameworks. The clinical/medical model identifies the mothers as being 'ill', and the social science model suggests a particular vulnerability to additional social stress factors. Despite attempts to predict those women at risk, and develop preventative programmes, most treatment initiatives are reactive, which is a direct result of the inconclusive nature of available evidence. The study reported here suggests that the concept 'postnatal depression' needs to be re-examined and that rather than it being an individual illness or vulnerability, it is more akin to a normal grief reaction and part of a normal postnatal profile. It only becomes a problem when it is defined and treated inappropriately. The implications from this research lead to a new approach to understanding the mother's experience of postnatal depression, and types of counselling and support which might effectively be employed by midwives and health visitors.

Use of the Edinburgh Postnatal Depression Scale in some Swedish child health care centres

A Swedish version of the Edinburgh Postnatal Depression Scale was validated in 53 women, in comparison with an interview based on the Comprehensive Psychopathological Rating Scale (CPRS-Depression). The EPDS was then applied to 258 women on four occasions, first at 2 and 6 weeks and then at 3 and 8 months post partum. At 2 weeks the proportion of women with signs of depression was 26%, 8% at 6 weeks, 13% at 3 months and 8% at 8 months. An analysis of the 10 items in the EPDS was performed. The subjects felt the questionnaire to express their situation accurately and relevantly. It was also regarded as easy to complete.

Breast engorgement: patterns and selected outcomes

For 14 days following birth, 114 breastfeeding mothers rated their level of breast engorgement twice daily, using a six-point engorgement scale. Individual engorgement ratings were plotted by intensity over time to provide a visual display of each subject's breast engorgement experience. Four distinct patterns of breast engorgement emerged; mothers experienced either a bell-shaped pattern, a multi-modal pattern, a pattern of intense engorgement, or a pattern of minimal engorgement. Characteristics of mothers and infants, and feeding frequency were similar across the four breast engorgement patterns.

The effectiveness of a self-care intervention for the management of postpartum fatigue

The purpose of this study was to test the effectiveness of the Tiredness Management Guide (TMG) as a self-care intervention for the management of postpartum fatigue from the second to the sixth week postpartum. An experimental repeated measures analysis of variance design was used with a sample of 68 primiparous mothers. Interaction effects between group membership and time in the hypothesized direction were found for fatigue. When the data were tested from the second through the fourth week, a significant interaction effect was found between group membership and time with the experimental group having lower morning fatigue. Results suggest that using the TMG may reduce levels of morning postpartum fatigue from the second through the fourth week postpartum.

A comparison of cold and warm sitz baths for relief of postpartum perineal pain

The effect of cold sitz baths for relieving perineal pain in the postpartum period after an episiotomy was evaluated. Forty patients took both cold and warm sitz baths with random assignment of the initial bath. Patients rated the degree of perineal pain before and after each sitz bath and at half-hour and one-hour intervals after each bath. A pain scale using 0-5, 0 representing no pain and 5 representing extreme pain, was used. Analysis of pain scale scores using a two-way analysis of variance with replications showed that cold sitz baths were significantly more effective in relieving perineal pain. The greatest amount of pain relief was experienced immediately after the cold sitz baths.

A pilot study of eye movement desensitisation and reprocessing treatment (EMDR) for post-traumatic stress after childbirth

OBJECTIVE

to explore the possibility of using eye movement desensitisation and reprocessing (EMDR) to treat women who have experienced post-traumatic stress after childbirth.

DESIGN

the pilot study consisted of a 'before and after' treatment design combined with follow-up measurements 1-3 years after EMDR treatment. Quantitative data from questionnaires (Traumatic Event Scale [TES]) were collected. In addition, qualitative data from individual interviews with the participants were collected as well as data from the psychotherapist's treatment notes of the EMDR treatment sessions.

SETTING

the north of Sweden.

PARTICIPANTS

four women with post-traumatic stress disorder (PTSD) after childbirth (one pregnant and three non-pregnant).

FINDINGS

all participants reported reduction of post-traumatic stress after treatment. After 1-3 years, the beneficial effects of EMDR treatment remained for three of the four women. Symptoms of intrusive thoughts and avoidance seemed most sensitive for treatment.

IMPLICATIONS FOR PRACTICE

EMDR might be a useful tool in the treatment of non-pregnant women severely traumatised by childbirth; however, further research is required.

Positioning intervention to minimize fatigue in breastfeeding women

Nursing interventions to enhance breastfeeding affect the health of mothers and babies. Fatigue may interfere with breastfeeding, so interventions minimizing fatigue are important. This repeated measures study of 20 postpartum women investigated the relative efficacy of one intervention, promoting use of the side-lying position. Using the Modified Fatigue Symptoms Checklist, fatigue was measured after breastfeeding in two positions. In mothers who had vaginal deliveries (n = 14), significantly less fatigue was reported following nursing in the side-lying versus the sitting position. Instruction regarding restfulness of the side-lying position should be considered as part of routine postpartum or home health nursing care.

Screening methods for postpartum depression

Nine to fifteen percent of women who have recently given birth experience postpartum depression; however, only a small portion of these women are identified as depressed by health professionals. To improve this poor detection rate, a new screening tool, the Postpartum Depression Checklist (PDC), was constructed, based on the findings of two qualitative studies. The PDC is a simple, practical device for use by health professionals that provides an opportunity to engage a woman actively in a dialogue about her experiences with the 11 symptoms included on the checklist. Its use by health professionals during the 1st year postpartum may help to ensure that mothers who experience postpartum depression receive treatment.

The impact of research findings on current practice in relieving postpartum perineal pain in a large district general hospital

In order to study the impact of research findings on current clinical practice 100 members of midwifery and medical staff of a large district general hospital were surveyed regarding their treatment of postpartum perineal pain. Of the 76 who responded only 20 (26%) referred to research findings to support their clinical practice and in only one case was the research appropriate to the population in question. Important research findings were not applied, while the majority of the reported practice was not research-based. Research-based practice is not only the responsibility of the individual clinician but also of those at educational and management levels. Local strategies should be developed and resources made available to facilitate research utilisation and implementation.

Reducing genital tract trauma at birth: launching a clinical trial in midwifery

Genital tract trauma is a common outcome of vaginal birth, and can cause short-term and long-term problems for new mothers. Preventive measures have not been fully explicated. Midwives use a variety of hand maneuvers late in the second stage of labor, in the belief that genital trauma can be reduced. However, none of these care measures have been rigorously tested to determine if they are effective. A midwifery practice offers an ideal setting to study the relationship of hand techniques by the birth attendant to reduction of genital tract trauma.

Health problems related to early discharge of Turkish women

OBJECTIVE

to determine women's problems when discharged early from hospital after normal vaginal birth among a simple convenience sample of mothers in one part of Turkey.

DESIGN

a descriptive interview study.

SETTING

primary health-care unit in Erzurum, Turkey.

PARTICIPANTS

112 mothers who came to the primary health-care unit for vaccination of their 2-month old babies between May and June 2000. Data were collected by structured face-to-face interviews. A symptom checklist was used to determine health problems.

FINDINGS

length of hospital stay after delivery was a mean of 7.1+/-7.0 hrs, and 66.1% (n=74) of mothers did not receive appropriate education about potential postpartum health problems. The findings indicated that the morbidity rate of mothers in the postpartum period was high. Among the most prevalent problems experienced by mothers were fatigue (86.6%; n=97), insomnia (80.4%; n=90), breast problems [engorged breast, tenderness and pain] 71.4%; n=80) and constipation 61.7%; n=69). Vaginal infection was reported by 16 mothers (14.3%; n=16). The prevalence of the use of medical services resulting from postnatal health problems in the postpartum period was 42.0% (n=47). About half of the mothers (51.8%; n=58) were not visited by midwives during the first postpartum week after discharge from hospital because both the maternity hospital and mother had not reported any health problems to the midwife. RECOMMENDATIONS FOR PRACTICE: mothers can experience many problems in the postpartum period. It is not possible to predict which mother will experience risks, such as an infection or mastitis. Therefore, women discharged from hospital in the first 24 hrs after birth should be educated about the problems that may arise during the postpartum period. They should also be given professional care and help in their own home by midwives working in the primary-care unit. Mothers should be told to notify their midwives about delivery and discharge in order to receive early follow-up in their homes. We suggest promoting maternal health education that encourages women to seek appropriate and timely care.

Deep vein thrombosis in pregnancy

This article provides a review of the incidence, pathophysiology, and treatment of deep vein thrombosis (DVT) in pregnancy, a rare but serious complication of pregnancy. The incidence of DVT in pregnancy varies widely, but it is a leading cause of maternal morbidity in both the United States and the United Kingdom. Risk factors during pregnancy include prolonged bed rest or immobility, pelvic or leg trauma, and obesity. Additional risk factors are preeclampsia, Cesarean section, instrument-assisted delivery, hemorrhage, multiparity, varicose veins, a previous history of a thromboembolic event, and hereditary or acquired thrombophilias such as Factor V Leiden. Heparin is the anticoagulant of choice to treat active thromboembolic disease or to administer for thromboprophylaxis, but low molecular-weight heparin is being used with increasing frequency in the pregnant woman. Perinatal nurses should be aware of the symptoms, diagnostic tools, and treatment options available to manage active thrombosis during pregnancy and in the intrapartum and postpartum periods.

'Listening visits' in pregnancy: a strategy for preventing postnatal depression?

OBJECTIVE

to examine existing research evidence to ascertain whether 'listening visits' in pregnancy, targeted at women with low emotional wellbeing, are likely to be effective in preventing postnatal depression and in improving other maternal psychological outcomes.

FINDINGS

the evidence currently available suggests that postnatal listening visits are effective in preventing postnatal depression; that many women who are depressed after childbirth were also depressed in pregnancy; and that psychological interventions in pregnancy can have beneficial effects on postnatal emotional wellbeing. Existing research also suggests that the Edinburgh Postnatal Depression Scale may be an appropriate tool for selecting women for antenatal 'listening visits'; and that a formal approach is likely to prove more beneficial than ad hoc approaches.

KEY CONCLUSIONS

it is concluded that 'listening visits' in pregnancy may well be a useful strategy for preventing postnatal depression. However, further research is necessary before antenatal 'listening visits' are introduced on a large scale.

IMPLICATIONS FOR PRACTICE

midwives might usefully consider introducing antenatal 'listening visits', auditing this new practice and disseminating findings.

Postnatal depression: what can a health visitor do?

Postnatal depression has been a subject that has provoked interest and research for many years. Marce published a paper in 1858 on puerperal and lactational psychoses, and since then many other writers have pursued different avenues of interest, primary cause, affect and treatment. A great deal of this work over the years has been done by psychiatrists and physicians, principally being interested in the more severe postpartum psychosis, when many of those suffering are admitted to an acute psychiatric hospital. However, as research has continued the less severe forms of postnatal depression and the upsetting effect they have on the patient's family continue to be a source of concern, not only to the professionals themselves, but more importantly, to the mothers who are suffering from this very upsetting problem. Professor Cox stated that he found it ironical that primary care workers regularly visited mothers in the puerperium and only rarely recognized postnatal depression. This led me to believe that we, as health visitors, should set about trying to put this right. As Professor Cox rightly said, it's a sad paradox that considering the medical scrutiny mothers receive over the antenatal and postnatal period, many depressed mothers still are not identified. The author therefore attempts to devise some kind of strategies for health visitors to identify mothers suffering from postnatal depression, and considers whether any links can be found between those suffering from postnatal depression.

Reproductive Health in Women With Eating Disorders

Medical complications are often the precipitants that lead women with eating disorders to seek health care. Complications can be wide ranging but frequently include symptoms associated with reproductive health. Unfortunately, because of the denial, embarrassment, shame, and secrecy associated with these psychiatric illnesses, the underlying cause of these complications can often go unacknowledged, delaying assessment and intervention. This article provides an overview of anorexia nervosa and bulimia nervosa, identifies the reproductive health issues that may occur in women with these disorders, and discusses the associated clinical implications for nursing practice.

Minimizing postpartum pain: a review of research pertaining to perineal care in childbearing women

This paper provides a review of literature that relates to perineal pain and care. Articles evaluated include systematic reviews and research papers from the disciplines of midwifery, physiotherapy and obstetrics. The major themes to emerge from the literature and be reviewed are the need for episiotomy, suturing methods and materials, assessment of perineal trauma, treatment of perineum in the postpartum period, and postpartum recovery. Research has highlighted that many practices relating to perineal care remain un-researched and therefore the need for evaluation is urgent. Further postpartum morbidity has been seen to affect many women, but is often unrecognized by practitioners. It is also a topic that requires further evaluation through well-designed and implemented research.

Women with high-risk pregnancies, problems, and APN interventions

PURPOSE

To (a) describe women's prenatal and postpartum problems and advanced practice nurses (APN) interventions; and (b) determine if problems and APN interventions differed by women's medical diagnosis (diabetes, hypertension, preterm labor).

DESIGN AND METHODS

Content analysis of 85 interaction logs created by APNs during a randomized clinical trial in which half of physician-provided prenatal care was substituted with APN-provided prenatal care in the women's homes. Patients' problems and APN interventions were classified with the Omaha Classification System.

FINDINGS

A total of 212,835 health problems and 212,835 APN interventions were identified. The dominant antenatal problems were physiologic (59.2%) and health-related behaviors (33.3%); postpartum were physiologic (44.0%) and psychosocial problems (31.6%). Antenatally, women with diabetes had significantly more health-related behavior problems; women with preterm labor had more physiologic problems. APN surveillance interventions predominated antenatally (65.6%) and postpartum (66.0%), followed by health teaching, guidance, and counseling both antenatally (25.4%) and postpartum (28.1%). Women with chronic hypertension required significantly more case-management interventions.

CONCLUSIONS

The categories of women's problems were largely similar across medical diagnostic groups. Interventions to address women's problems ranged from assessing maternal and fetal physiologic states to teaching interpersonal relationships and self-care management to assisting with transportation and housing. Data show the range of APN knowledge and skills needed to improve maternal and infant outcomes and ultimately reduce healthcare costs in women with high-risk pregnancies.