Physiotherapy in Obstetrics and Gynaecology - 2nd Edition

Appendix 1: ICS standardisation of terminology 2002 445 • Chronic retention of urine is defined as a non-painful bladder, which remains palpable or percussable after the patient has passed urine. Such patients may be incontinent. (NEW)43 • Benign prostatic obstruction is a form of bladder outlet obstruction; and may be diagnosed when the cause of outlet obstruction is known to be benign prostatic enlargement, due to histologic benign prostatic hyperplasia. (NEW) • Benign prostatic hyperplasia is a term used (and reserved for) the typ- ical histological pattern which defines the disease. (NEW) • Benign prostatic enlargement is defined as prostatic enlargement due to histologic benign prostatic hyperplasia. The term ‘prostatic enlarge- ment’ should be used in the absence of prostatic histology. (NEW) 5 TREATMENT The following definitions were published in the 7th ICS report on Lower Urinary Tract Rehabilitation Techniques (3) and remain in their original form. 5.1 LOWER Lower urinary tract rehabilitation is defined as non-surgical, non- phar- URINARY TRACT macological treatment for lower urinary tract function and includes: REHABILITATION • Pelvic floor training defined as repetitive selective voluntary contrac- tion and relaxation of specific pelvic floor muscles. • Biofeedback is the technique by which information about a normally unconscious physiological process is presented to the patient and/or the therapist as a visual, auditory or tactile signal. • Behavioural modification is defined as the analysis and alteration of the relationship between the patient’s symptoms and his or her envir- onment for the treatment of maladaptive voiding patterns. This may be achieved by modification of the behaviour and/or envir- onment of the patient. 5.2 ELECTRICAL Electrical stimulation is the application of electrical current to stimulate STIMULATION the pelvic viscera or their nerve supply. The aim of electrical stimulation may be to directly induce a therapeutic response or to modulate lower urinary tract, bowel or sexual dysfunction. 5.3 CATHETERISATION Catheterisation is a technique for bladder emptying employing a catheter to drain the bladder or a urinary reservoir. 43The ICS no longer recommends the term ‘overflow incontinence’. This term is considered confusing and lacking a convincing definition. If used, a precise definition and any associated pathophysiology, such as reduced urethral function, or detrusor overactivity/ low bladder compliance, should be stated. The term chronic retention, excludes transient voiding difficulty, for example after surgery for stress incontinence, and implies a significant residual urine; a minimum figure of 300 mL has been previously mentioned.

446 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY 5.3.1 Intermittent Intermittent (in/out) catheterisation is defined as drainage or aspiration (in/out) catheterisation of the bladder or a urinary reservoir with subsequent removal of the catheter. The following types of intermittent catheterisation are defined: • Intermittent self-catheterisation is performed by the patient himself/ herself • Intermittent catheterisation is performed by an attendant (e.g. doctor, nurse or relative) • Clean intermittent catheterisation: use of a clean technique. This implies ordinary washing techniques and use of disposable or cleansed reusable catheters. • Aseptic intermittent catheterisation: use of a sterile technique. This implies genital disinfection and the use of sterile catheters and instru- ments/gloves. 5.3.2 Indwelling Indwelling catheterisation: an indwelling catheter remains in the bladder, catheterisation urinary reservoir or urinary conduit for a period of time longer than one emptying. 5.4 BLADDER REFLEX Bladder reflex triggering comprises various manoeuvres performed by TRIGGERING the patient or the therapist in order to elicit reflex detrusor contraction by exteroceptive stimuli. The most commonly used manoeuvres are; suprapubic tapping, thigh scratching and anal/rectal manipulation. 5.5 BLADDER Bladder expression comprises various manoeuvres aimed at increasing EXPRESSION intravesical pressure in order to facilitate bladder emptying. The most commonly used manoeuvres are abdominal straining, Valsalva’s manoeuvre and Credé manoeuvre. ACKNOWLEDGEMENTS The authors of this report are very grateful to Vicky Rees, Administrator of the ICS, for her typing and editing of numerous drafts of this document. ADDENDUM The terminology committee was announced at the ICS meeting in Denver 1999 and expressions of interest were invited from those who wished to be Formation of the ICS active members of the committee and they were asked to comment in terminology committee detail on the preliminary draft (the discussion paper published in Neurourology and Urodynamics). The nine authors replied with a detailed critique by 1st April 2000 and constitute the committee: Paul Abrams, Linda Cardozo, Magnus Fall, Derek Griffiths, Peter Rosier, Ulf Ulmsten, Philip van Kerrebroeck, Arne Victor, and Alan Wein. We thank other individuals who later offered their written comments: Jens Thorup Andersen, Walter Artibani, Jerry Blaivas, Linda Brubaker, Rick Bump, Emmanuel Chartier-Kastler, Grace Dorey, Clare Fowler, Kelm Hjalmas, Gordon Hosker, Vik Khullar, Guus Kramer, Gunnar Lose, Joseph Macaluso, Anders Mattiasson, Richard Millard, Rien

Appendix 1: ICS standardisation of terminology 2002 447 Nijman, Arwin Ridder, Werner Schäfer, David Vodusek, and Jean Jacques Wyndaele. A ⁄12 day workshop was held at the ICS Annual Meeting in Tampere (August 2000) and a two-day meeting in London, January 2001, which produced draft 5 of the report which was then placed on the ICS website (www.icsoffice.org). Discussions on draft 6 took place at the ICS meeting in Korea September 2001, draft 7 then remained on the ICS website until final submission to journals in November 2001. References Abrams P (Chair), Blaivas J G, Stanton S, Andersen J T. 1988. standardisation sub-committee of the International ICS standardisation of terminology of lower urinary tract Continence Society. Neurourol Urodyn (In press). function. Neurourol Urodyn 7:403–426. Mattiasson A, Djurhuus J C, Fonda D, Lose G, Nordling J, Stöhrer M. 1998. Standardisation of outcome studies in Abrams P, Blaivas J G, Stanton S L, Andersen J. 1992. ICS 6th patients with lower urinary dysfunction: a report on report on the standardisation of terminology of lower general principles from the standardisation committee of urinary tract function. Neurourol Urodyn 11:593–603. the International Continence Society. Neurourol Urodyn 17:249–253. Andersen J T, Blaivas J G, Cardozo L, Thüroff J. 1992. ICS 7th Nordling J, Abrams P, Ameda K, Andersen J T, Donovan J, report on the standardisation of terminology of lower Griffiths D, Kobayashi S, Koyanagi T, Schäfer W, Yalla S, urinary tract function: lower urinary tract rehabilitation Mattiasson A. 1998. Outcome measures for research in techniques. Neurourol Urodyn 11:593–603. treatment of adult males with symptoms of lower urinary tract dysfunction. Neurourol Urodyn 17:263–271. Bump R C, Mattiasson A, Bo K, Brubaker L P, DeLancey J O L, Stöhrer M, Goepel M, Kondo A, Kramer G, Madersbacher H, Klarskov P, Shull B L, Smith A R B. 1996. The Millard R, Rossier A, Wyndaele J J. 1999. ICS report on standardisation of terminology of female pelvic organ the standardisation of terminology in neurogenic lower prolapse and pelvic floor dysfunction. Am J Obstet urinary tract dysfunction. Neurourol Urodyn 18:139–158. Gynecol 175:10–11. Schäfer W, Sterling A M, Liao L, Spangberg A, Pesce F, Zinner N R, van Kerrebroeck P, Abrams P, Mattiasson A. Fonda D, Resnick N M, Colling J, Burgio K, Ouslander J G, 2002. Good urodynamic practice: report from the Norton C, Ekelund P, Versi E, Mattiasson A. 1998. standardisation sub-committee of the International Outcome measures for research of lower urinary tract Continence Society. Neurourol Urodyn (In press).* dysfunction in frail and older people. Neurourol Urodyn van Waalwijk van Doorn E, Anders K, Khullar V, Kulseng- 17:273–281. Hansen S, Pesce F, Robertson A, Rosario D, Schäfer W. 2000. Standardisation of ambulatory urodynamic Griffiths D, Höfner K, van Mastrigt R, Rollema H J, monitoring: report of the standardisation sub-committee Spangberg A, Gleason D. 1997. ICS report on the of the International Continence Soceity for ambulatory standardisation of terminology of lower urinary tract urodynamic studies. Neurourol Urodyn 19:113–125. function: pressure-flow studies of voiding, urethral van Kerrebroeck P, Abrams P, Chaikin D, Donovan J, Fonda resistance and urethral obstruction. Neurourol Urodyn D, Jackson S, Jennum P, Johnson T, Lose G, Mattiasson A, 16:1–18. Robertson G, Weiss J. 2002. ICS standardisation report on nocturia: report from the standardisation sub-committee International Classification of Functioning, Disability and of the International Continence Society. Neurourol Health. ICIDH-2 website http://www.who.int/icidh. Urodyn 21:193–199. wan D, James E D, Kramer A E J L, Sterling A M, Suhel P F. Klevmark B. 1999. Natural pressure: volume curves and 1987. ICS report on urodynamic equipment: technical conventional cystometry. Scand J Urol Nephrol Suppl aspects. J Med Eng Technol 11(2):57–64. 201:1–4. * Now published as: Schäfer W, Abrams P, Liao L, Mattiason Lose G, Fanti J A, Victor A, Walter S, Wells T L, Wyman J, A, Pesce F, Spangberg A, Sterling A, Zinner N, van Mattiasson A. 1998. Outcome measures for research in Kerrebroeck P 2002 Good urodynamic practices: uroflow- adult women with symptoms of lower urinary tract metry, filling cystometry and pressure-flow studies. dysfunction. Neurourol Urodyn 17:255–262. Neurourol Urodyn 21:261–274. Lose G, Griffiths D, Hosker G, Kulseng-Hanssen S, Perucchini D, Schäfer W, Thind P, Versi E. Standardisation of urethral pressure measurement: report from the

449 Appendix 2 Standardisation of terminology of lower urinary tract function Reproduced with permission of the International Continence Society Committee on Standardisation of Terminology. First published in Scandinavian Journal of Urology and Nephrology, Supplementum 114, 1988 Members: Paul Abrams, Jerry G. Blaivas, Stuart L. Stanton and Jens T. Andersen (Chairman) 1 INTRODUCTION The International Continence Society established a committee for the stan- dardisation of terminology of lower urinary tract function in 1973. Five of the six reports (1,2,3,4,5) from this committee, approved by the Society, have been published. The fifth report on ‘Quantification of urine loss’ was an internal I.C.S. document but appears, in part, in this document. These reports are revised, extended and collated in this monograph. The standards are recommended to facilitate comparison of results by investigators who use urodynamic methods. These standards are recom- mended not only for urodynamic investigations carried out on humans but also during animal studies. When using urodynamic studies in ani- mals the type of any anaesthesia used should be stated. It is suggested that acknowledgement of these standards in written publications be indicated by a footnote to the section ‘Methods and Materials’ or its equivalent, to read as follows: ‘Methods, definitions and units conform to the standards recommended by the International Continence Society, except where specifically noted’. Urodynamic Studies involve the assessment of the function and dys- function of the urinary tract by any appropriate method. Aspects of urin- ary tract morphology, physiology, biochemistry and hydrodynamics affect urine transport and storage. Other methods of investigation such as the radiographic visualisation of the lower urinary tract is a useful adjunct to conventional urodynamics. This monograph concerns the urodynamics of the lower urinary tract.

450 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY 2 CLINICAL ASSESSMENT The clinical assessment of patients with lower urinary tract dysfunction should consist of a detailed history, a frequency/volume chart and a physical examination: In urinary incontinence, leakage should be demonstrated objectively. 2.1 HISTORY The general history should include questions relevant to neurological and congential abnormalities as well as information on previous urinary infections and relevant surgery. Information must be obtained on medi- cation with known or possible effects on the lower urinary tract. The general history should also include assessment of menstrual, sexual and bowel function, and obstetric history. The urinary history must consist of symptoms related to both the stor- age and the evacuation functions of the lower urinary tract. 2.2 FREQUENCY/ The frequency/volume chart is a specific urodynamic investigation VOLUME recording fluid intake and urine output per 24 hour period. The chart CHART gives objective information on the number of voidings, the distribution of voidings between daytime and nighttime and each voided volume. The chart can also be used to record episodes of urgency and leakage and the number of incontinence pads used. The frequency/volume chart is very useful in the assessment of voiding disorders, and in the follow-up of treatment. 2.3 PHYSICAL Besides a general urological and, when appropriate, gynaecological EXAMINATION examination, the physical examination should include the assessment of perineal sensation, the perineal reflexes supplied by the sacral segments S2–S4, and anal sphincter tone and control. 3 PROCEDURES RELATED TO THE EVALUATION OF URINE STORAGE 3.1 CYSTOMETRY Cystometry is the method by which the pressure/volume relationship of the bladder is measured. All systems are zeroed at atmospheric pressure. For external transducers the reference point is the level of the superior edge of the symphysis pubis. For catheter mounted transducers the ref- erence point is the transducer itself. Cystometry is used to assess detrusor activity, sensation, capacity and compliance. Before starting to fill the bladder the residual urine may be measured. However, the removal of a large volume of residual urine may alter detru- sor function especially in neuropathic disorders. Certain cystometric param- eters may be significantly altered by the speed of bladder filling (see 6.1.1.4).

Appendix 2: ICS standardisation of terminology 1988 451 During cystometry it is taken for granted that the patient is awake, unanaesthetised and neither sedated nor taking drugs that affect bladder function. Any variations should be specified. Specify (a) Access (transurethral or percutaneous). (b) Fluid medium (liquid or gas). (c) Temperature of fluid (state in degrees Celsius). (d) Position of patient (e.g. supine, sitting or standing). (e) Filling may be by diuresis or catheter. Filling by catheter may be con- tinuous or incremental; the precise filling rate should be stated. When the incremental method is used the volume increment should be stated. For general discussion, the following terms for the range of filling rate may be used: (i) up to 10 ml per minute is slow fill cystometry (‘physiological’ filling). (ii) 10–100 ml per minute is medium fill cystometry. (iii) over 100 ml per minute is rapid fill cystometry. Technique (a) Fluid-filled catheter – specify number of catheters, single or multiple lumens, type of catheter (manufacturer), size of catheter. (b) Catheter tip transducer – list specifications. (c) Other catheters – list specifications. (d) Measuring equipment. Definitions Intravesical pressure is the pressure within the bladder. Abdominal pressure is taken to be the pressure surrounding the bladder. In current practice it is estimated from rectal or, less commonly, extraperi- toneal pressure. Detrusor pressure is that component of intravesical pressure that is cre- ated by forces in the bladder wall (passive and active). It is estimated by subtracting abdominal pressure from intravesical pressure. The simultan- eous measurement of abdominal pressure is essential for the interpret- ation of the intravesical pressure trace. However, artifacts on the detrusor pressure trace may be produced by intrinsic rectal contractions. Bladder sensation. Sensation is difficult to evaluate because of its sub- jective nature. It is usually assessed by questioning the patient in relation to the fullness of the bladder during cystometry. Commonly used descriptive terms include: First desire to void Normal desire to void (this is defined as the feeling that leads the patient to pass urine at the next convenient moment, but voiding can be delayed if necessary). Strong desire to void (this is defined as a persistent desire to void with- out the fear of leakage). Urgency (this is defined as a strong desire to void accompanied by fear of leakage or fear of pain).

452 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY Pain (the site and character of which should be specified). Pain during bladder filling or micturition is abnormal. The use of objective or semi-objective tests for sensory function, such as electrical threshold studies (sensory testing), is discussed in detail in 5.5. The term ‘Capacity’ must be qualified. Maximum cystometric capacity, in patients with normal sensation, is the volume at which the patient feels he/she can no longer delay micturition. In the absence of sensation the maximum cystometric capacity cannot be defined in the same terms and is the volume at which the clinician decides to terminate filling. In the presence of sphincter incompetence the maximum cystometric capacity may be significantly increased by occlusion of the urethra e.g. by Foley catheter. The functional bladder capacity, or voided volume is more relevant and is assessed from a frequency/volume chart (urinary diary). The maximum (anaesthetic) bladder capacity is the volume measured after filling during a deep general or spinal/epidural anaesthetic, speci- fying fluid temperature, filling pressure and filling time. Compliance indicates the change in volume for a change in pressure. Compliance is calculated by dividing the volume change (⌬V ) by the change in detrusor pressure (⌬pdet) during that change in bladder volume (C ϭ ⌬V/⌬pdet). Compliance is expressed as mls per cm H2O (see 6.1.1.4). 3.2 URETHRAL It should be noted that the urethral pressure and the urethral closure PRESSURE pressure are idealized concepts which represent the ability of the urethra to prevent leakage (see 6.1.5). In current urodynamic practice the urethral MEASUREMENT pressure is measured by a number of different techniques which do not always yield consistant values. Not only do the values differ with the method of measurement but there is often lack of consistency for a single method. For example the effect of catheter rotation when urethral pres- sure is measured by a catheter mounted transducer. Intraluminal urethral pressure may be measured: (a) At rest, with the bladder at any given volume. (b) During coughing or straining. (c) During the process of voiding (see 4.4). Measurements may be made at one point in the urethra over a period of time, or at several points along the urethra consecutively forming a urethral pressure profile (U.P.P.). Storage phase Two types of U.P.P. may be measured: (a) Resting urethral pressure profile – with the bladder and subject at rest. (b) Stress urethral pressure profile – with a defined applied stress (e.g. cough, strain, valsalva).

Appendix 2: ICS standardisation of terminology 1988 453 In the storage phase the urethral pressure profile denotes the intralumi- nal pressure along the length of the urethra. All systems are zeroed at atmospheric pressure. For external transducers the reference point is the superior edge of the symphysis pubis. For catheter mounted transducers the reference point is the transducer itself. Intravesical pressure should be measured to exclude a simultaneous detrusor contraction. The sub- traction of intravesical pressure from urethral pressure produces the urethral closure pressure profile. The simultaneous recording of both intravesical and intra-urethral pressures are essential during stress urethral profilometry. Specify (a) Infusion medium (liquid or gas). (b) Rate of infusion. (c) Stationary, continuous or intermittent withdrawal. (d) Rate of withdrawal. (e) Bladder volume. (f) Position of patient (supine, sitting or standing). Technique (a) Open catheter – specify type (manufacturer), size, number, position and orientation of side or end hole. (b) Catheter mounted transducers – specify manufacturer, number of transducers, spacing of transducers along the catheter, orientation with respect to one another; transducer design e.g. transducer face depressed or flush with catheter surface; catheter diameter and mater- ial. The orientation of the transducer(s) in the urethra should be stated. (c) Other catheters, e.g. membrane, fibreoptic – specify type (manufac- turer), size and number of channels as for microtransducer catheter. (d) Measurement technique: For stress profiles the particular stress employed should be stated e.g. cough or valsalva. (e) Recording apparatus: Describe type of recording apparatus. The fre- quency response of the total system should be stated. The frequency response of the catheter in the perfusion method can be assessed by blocking the eyeholes and recording the consequent rate of change of pressure. Definitions Fig. A2.1: Referring to profiles measured in storage phase. Maximum urethral pressure is the maximum pressure of the measured profile. Maximum urethral closure pressure is the maximum difference between the urethral pressure and the intravesical pressure. Functional profile length is the length of the urethra along which the urethral pressure exceeds intravesical pressure. Functional profile length (on stress) is the length over which the urethral pressure exceeds the intravesical pressure on stress. Pressure ‘transmission’ ratio is the increment in urethral pressure on stress as a percentage of the simultaneously recorded increment in intravesical pressure. For stress profiles obtained during coughing, pressure transmis- sion ratios can be obtained at any point along the urethra. If single values

454 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY Figure A2.1 Diagram of a 120 female urethral pressure profile (static) with I.C.S. Intraurethral pressure (cm H2O) 100 recommended nomenclature. 80 Maximum Maximum urethral urethral 60 closure pressure pressure 56 40 20 Bladder Functional profile length pressure Total profile length 0 234 Distance (cm) 01 are given the position in the urethra should be stated. If several pressure transmission ratios are defined at different points along the urethra a pressure ‘transmission’ profile is obtained. During ‘cough profiles’ the amplitude of the cough should be stated if possible. Note: the term ‘transmission’ is in common usage and cannot be changed. However transmission implies a completely passive process. Such an assumption is not yet justified by scientific evidence. A role for muscular activity cannot be excluded. Total profile length is not generally regarded as a useful parameter. The information gained from urethral pressure measurements in the storage phase is of limited value in the assessment of voiding disorders. 3.3 QUANTIFICATION Subjective grading of incontinence may not indicate reliably the degree OF URINE LOSS of abnormality. However it is important to relate the management of the individual patients to their complaints and personal circumstances, as well as to objective measurements. In order to assess and compare the results of the treatment of different types of incontinence in different centres, a simple standard test can be used to measure urine loss objectively in any subject. In order to obtain a repre- sentative result, especially in subjects with variable or intermittent urinary incontinence, the test should occupy as long a period as possible; yet it must be practical. The circumstances should approximate to those of everyday life, yet be similar for all subjects to allow meaningful comparison. On the basis of pilot studies performed in various centres, an internal report of the I.C.S. (5th) recommended a test occupying a one-hour period during which a series of standard activities was carried out. This test can be extended by further one hour periods if the result of the first one hour test was not con- sidered representative by either the patient or the investigator. Alternatively the test can be repeated having filled the bladder to a defined volume. The total amount of urine lost during the test period is determined by weighing a collecting device such as a nappy, absorbent pad or condom appliance. A nappy or pad should be worn inside waterproof underpants or should have a waterproof backing. Care should be taken to use a col- lecting device of adequate capacity.

Appendix 2: ICS standardisation of terminology 1988 455 Immediately before the test begins the collecting device is weighed to the nearest gram. Typical test schedule (a) Test is started without the patient voiding. (b) Preweighed collecting device is put on and first one hour test period begins. (c) Subject drinks 500 ml sodium free liquid within a short period (max. 15 min), then sits or rests. (d) Half hour period: subject walks, including stair climbing equivalent to one flight up and down. (e) During the remaining period the subject performs the following activities: (i) standing up from sitting, 10 times (ii) coughing vigorously, 10 times (iii) running on the spot for 1 minute (iv) bending to pick up small object from floor, 5 times (v) wash hands in running water for 1 minute (f) At the end of the one hour test the collecting device is removed and weighed. (g) If the test is regarded as representative the subject voids and the vol- ume is recorded. (h) Otherwise the test is repeated preferably without voiding. If the collecting device becomes saturated or filled during the test it should be removed and weighed, and replaced by a fresh device. The total weight of urine lost during the test period is taken to be equal to the gain in weight of the collecting device(s). In interpreting the results of the test it should be born in mind that a weight gain of up to 1 gram may be due to weighing errors, sweating or vaginal discharge. The activity programme may be modified according to the subject’s physical ability. If substantial variations from the usual test schedule occur, this should be recorded so that the same schedule can be used on subsequent occasions. In principle the subject should not void during the test period. If the patient experiences urgency, then he/she should be persuaded to post- pone voiding and to perform as many of the activities in section (e) as pos- sible in order to detect leakage. Before voiding the collection device is removed for weighing. If inevitable voiding cannot be postponed then the test is terminated. The voided volume and the duration of the test should be recorded. For subjects not completing the full test the results may require separate analysis, or the test may be repeated after rehydration. The test result is given as grams urine lost in the one hour test period in which the greatest urine loss is recorded. Additional procedures Additional procedures intended to give information of diagnostic value are permissible provided they do not interfere with the basic test. For example, additional changes and weighing of the collecting device can give information about the timing of urine loss. The absorbent nappy may be an electronic recording nappy so that the timing is recorded directly.

456 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY Presentation of results (a) collecting device Specify (b) physical condition of subject (ambulant, chair-bound, bedridden) (c) relevant medical condition of subject (d) relevant drug treatments (e) test schedule. In some situations the timing of the test (e.g. in relation to the menstrual cycle) may be relevant. Findings Record weight of urine lost during the test (in the case of repeated tests, greatest weight in any stated period). A loss of less than one gram is within experimental error and the patients should be regarded as essen- tially dry. Urine loss should be measured and recorded in grams. Statistics When performing statistical analysis of urine loss in a group of subjects, non-parametric statistics should be employed, since the values are not normally distributed. 4 PROCEDURES RELATED TO THE EVALUATION OF MICTURITION 4.1 MEASUREMENT Urinary flow may be described in terms of rate and pattern and may be con- OF URINARY FLOW tinuous or intermittent. Flow rate is defined as the volume of fluid expelled Specify via the urethra per unit time. It is expressed in ml/s. Technique (a) Voided volume. Definitions (b) Patient environment and position (supine, sitting or standing). (c) Filling: (i) by diuresis (spontaneous or forced: specify regimen), (ii) by catheter (transurethral or suprapubic). (d) Type of fluid. (a) Measuring equipment. (b) Solitary procedure or combined with other measurements. (a) Continuous flow (Fig. A2.2) Voided volume is the total volume expelled via the urethra. Maximum flow rate is the maximum measured value of the flow rate. Average flow rate is voided volume divided by flow time. The calcula- tion of average flow rate is only meaningful if flow is continuous and without terminal dribbling. Flow time is the time over which measurable flow actually occurs. Time to maximum flow is the elapsed time from onset of flow to max- imum flow. The flow pattern must be described when flow time and average flow rate are measured. (b) Intermittent flow (Fig. A2.3) The same parameters used to characterise continuous flow may be appli- cable if care is exercised in patients with intermittent flow. In measuring flow time the time intervals between flow episodes are disregarded.

Appendix 2: ICS standardisation of terminology 1988 457 Figure A2.2 Diagram of a Flow rate (mL /s) continuous urine flow recording with I.C.S. recommended Maximum nomenclature. flow rate Voided volume Time to Time (s) maximum flow Flow time Figure A2.3 Diagram of an Flow rate (mL /s) interrupted urine flow recording with I.C.S. recommended nomenclature. Voiding time Time (s) Voiding time is total duration of micturition, i.e. includes interruptions. When voiding is completed without interruption, voiding time is equal to flow time. 4.2 BLADDER The specifications of patient position, access for pressure measure- PRESSURE ment, catheter type and measuring equipment are as for cystometry (see 3.1). MEASUREMENTS DURING MICTURITION Definitions (Fig. A2.4) Opening time is the elapsed time from initial rise in detrusor pressure to onset of flow. This is the initial isovolumetric contraction period of mic- turition. Time lags should be taken into account. In most urodynamic systems a time lag occurs equal to the time taken for the urine to pass from the point of pressure measurement to the uroflow transducer. The following parameters are applicable to measurements of each of the pressure curves: intravesical, abdominal and detrusor pressure. Premicturition pressure is the pressure recorded immediately before the initial isovolumetric contraction. Opening pressure is the pressure recorded at the onset of measured flow. Maximum pressure is the maximum value of the measured pressure. Pressure at maximum flow is the pressure reorded at maximum meas- ured flow rate. Contraction pressure at maximum flow is the difference between pressure at maximum flow and premicturition pressure.

458 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY Abdominal Abdominal Abdominal Maximum premicturition opening pressure at abdominal pressure pressure maximum flow pressure Abdominal Pabd cont max. flow pressure (cm H2O) Intravesical pressure at Intravesical maximum flow opening pressure Intravesical Intravesical Intravesical pressure premicturition (cm H2O) pressure contraction Maximum pressure at intravesical maximum flow pressure Detrusor Detrusor opening pressure at pressure maximum flow Detrusor Detrusor Maximum Detrusor pressure premicturition detrusor contraction (cm H2O) pressure pressure pressure at maximum flow Flow rate Maximum flow (ml/s) Opening time Figure A2.4 Diagram of a Postmicturition events (e.g. after contraction) are not well understood pressure-flow recording of and so cannot be defined as yet. micturition with I.C.S. recommended nomenclature. 4.3 PRESSURE FLOW In the early days of urodynamics the flow rate and voiding pressure were RELATIONSHIPS related as a ‘urethral resistance factor’. The concept of a resistance factor originates from rigid tube hydrodynamics. The urethra does not gener- ally behave as a rigid tube as it is an irregular and distensible conduit whose walls and surroundings have active and passive elements and hence, influence the flow through it. Therefore a resistance factor cannot provide a valid comparison between patients. There are many ways of displaying the relationships between flow and pressure during micturition, an example is suggested in the I.C.S. 3rd Report (4) (Fig. A2.5). As yet available data do not permit a standard presentation of pressure/flow parameters.

Figure A2.5 Diagram Detrusor pressure (cm H2O) Appendix 2: ICS standardisation of terminology 1988 459 illustrating the presentation of pressure flow data on individual Obstructed patients in three groups of 3 Unobstructed patients: obstructed, equivocal Equivocal and unobstructed. Flow rate (mL /s) When data from a group of patients are presented, pressure-flow rela- tionships may be shown on a graph as illustrated in Fig. A2.5. This form of presentation allows lines of demarcation to be drawn on the graph to separate the results according to the problem being studied. The points shown in Fig. A2.5 are purely illustrative to indicate how the data might fall into groups. The group of equivocal results might include either an unrepresentative micturition in an obstructed or an unobstructed patient, or underactive detrusor function with or without obstruction. This is the group which invalidates the use of ‘urethral resistance factors’. 4.4 URETHRAL The V.U.P.P. is used to determine the pressure and site of urethral PRESSURE obstruction. MEASUREMENTS Pressure is recorded in the urethra during voiding. The technique is DURING VOIDING similar to that used in the U.P.P. measured during storage (the resting and stress profiles (see 3.2)). (V.U.P.P.) Specify: as for U.P.P. during storage (see 3.2). Accurate interpretation of the V.U.P.P. depends on the simultaneous measurement of intravesical pressure and the measurement of pressure at a precisely localised point in the urethra. Localisation may be achieved by radio opaque marker on the catheter which allows the pressure meas- urements to be related to a visualised point in the urethra. This technique is not fully developed and a number of technical as well as clinical problems need to be solved before the V.U.P.P. is widely used. RESIDUAL URINE Residual urine is defined as the volume of fluid remaining in the bladder immediately following the completion of micturition. The measurement of residual urine forms an integral part of the study of micturition. However voiding in unfamiliar surroundings may lead to unrepresentative results, as may voiding on command with a partially filled or overfilled bladder. Residual urine is commonly estimated by the following methods: (a) Catheter or cystoscope (transurethral, supra-pubic). (b) Radiography (excretion urography, micturition cystography). (c) Ultrasonics. (d) Radioisotopes (clearance, gamma camera).

460 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY When estimating residual urine the measurement of voided volume and the time interval between voiding and residual urine estimation should be recorded: this is particularly important if the patient is in a diuretic phase. In the condition of vesicoureteric reflux, urine may re-enter the bladder after micturition and may falsely be interpreted as residual urine. The presence of urine in bladder diverticula following micturition present spe- cial problems of interpretation, since a diverticulum may be regarded either as part of the bladder cavity or as outside the functioning bladder. The various methods of measurement each have limitations as to their applicability and accuracy in the various conditions associated with residual urine. Therefore it is necessary to choose a method appropriate to the clinical problems. The absence of residual urine is usually an obser- vation of clinical value, but does not exclude infravesical obstruction or bladder dysfunction. An isolated finding of residual urine requires con- firmation before being considered significant. 5 PROCEDURES RELATED TO NEUROPHYSIOLOGICAL EVALUATION OF THE URINARY TRACT DURING FILLING AND VOIDING 5.1 Electromyography (EMG) is the study of electrical potentials generated ELECTROMYOGRAPHY by the depolarisation of muscle. The following refers to striated muscle EMG. The functional unit in EMG is the motor unit. This is comprised of a single motor neurone and the muscle fibres it innervates. A motor unit action potential is the recorded depolarisation of muscle fibres which results from activation of a single anterior horn cell. Muscle action poten- tials may be detected either by needle electrodes, or by surface electrodes. Needle electrodes are placed directly into the muscle mass and permit visualisation of the individual motor unit action potentials. Surface electrodes are applied to an epithelial surface as close to the muscle under study as possible. Surface electrodes detect the action poten- tials from groups of adjacent motor units underlying the recording surface. EMG potentials may be displayed on an oscilloscope screen or played through audio amplifiers. A permanent record of EMG potentials can only be made using a chart recorder with a high frequency response (in the range of 10 kHz). EMG should be interpreted in the light of the patients symptoms, physical findings and urological and urodynamic investigations. General information (a) EMG (solitary procedure, part of urodynamic or other electrophysio- Specify logical investigation). (b) Patient position (supine, standing, sitting or other). (c) Electrode placement: (i) Sampling site (intrinsic striated muscle of the urethra, peri- urethral striated muscle, bulbocavernosus muscle, external anal sphincter, pubococcygeus or other). State whether sites are sin- gle or multiple, unilateral or bilateral. Also state number of samples per site.

Appendix 2: ICS standardisation of terminology 1988 461 (ii) Recording electrode: define the precise anatomical location of the electrode. For needle electrodes, include site of needle entry, angle of entry and needle depth. For vaginal or urethral surface electrodes state method of determining position of electrode. (iii) Reference electrode position. Note: ensure that there is no electrical interference with any other machines, e.g. X-ray apparatus. Technical information (a) Electrodes. Specify (i) Needle electrodes – design (concentric, bipolar, monopolar, single fibre, other) – dimensions (length, diameter, recording area). – electrode material (e.g. platinum). (ii) Surface electrodes. – type (skin, plug, catheter, other) – size and shape – electrode material – mode of fixation to recording surface – conducting medium (e.g. saline, jelly) (b) Amplifier (make and specifications). (c) Signal processing (data: raw, averaged, integrated or other). (d) Display equipment (make and specifications to include method of calibration, time base, full scale deflection in microvolts and polarity). (i) oscilloscope (ii) chart recorder (iii) loudspeaker (iv) other (e) Storage (make and specifications). (i) paper (ii) magnetic tape recorder (iii) microprocessor (iv) other (f) Hard copy production (make and specifications). (i) chart recorder (ii) photographic/video reproduction of oscilloscope screen (iii) other. EMG Findings (a) Individual motor unit action potentials – Normal motor unit potentials have a characteristic configuration, amplitude and duration. Abnormal- ities of the motor unit may include an increase in the amplitude, dura- tion and complexity of waveform (polyphasicity) of the potentials. A polyphasic potential is defined as one having more than 5 deflections. The EMG findings of fibrillations, positive sharp waves and bizarre high frequency potentials are thought to be abnormal. (b) Recruitment patterns – In normal subjects there is a gradual increase in ‘pelvic floor’ and ‘sphincter’ EMG activity during bladder filling. At the onset of micturition there is complete absence of activity. Any

462 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY sphincter EMG activity during voiding is abnormal unless the patient is attempting to inhibit micturition. The finding of increased sphinc- ter EMG activity, during voiding, accompanied by characteristic simultaneous detrusor pressure and flow changes is described by the term, detrusor-sphincter-dyssynergia. In this condition a detrusor contraction occurs concurrently with an inappropriate contraction of the urethral and or periurethral striated muscle. 5.2 NERVE Nerve conduction studies involve stimulation of a peripheral nerve, and CONDUCTION STUDIES recording the time taken for a response to occur in muscle, innervated by the nerve under study. The time taken from stimulation of the nerve to the response in the muscle is called the ‘latency’. Motor latency is the time taken by the fastest motor fibres in the nerve to conduct impulses to the muscle and depends on conduction distance and the conduction velocity of the fastest fibres. General information (Also applicable to reflex latencies and evoked potentials – see below.) Specify (a) Type of investigation. (i) nerve conduction study (e.g. pudendal nerve) (ii) reflex latency determination (e.g. bulbocavernosus) (iii) spinal evoked potential (iv) cortical evoked potential (v) other (b) Is the study a solitary procedure or part of urodynamic or neuro- physiological investigations? (c) Patient position and environmental temperature, noise level and illumination. (d) Electrode placement: Define electrode placement in precise anatom- ical terms. The exact interelectrode distance is required for nerve con- duction velocity calculations. (i) Stimulation site (penis, clitoris, urethra, bladder neck, bladder or other). (ii) Recording sites (external anal sphincter, periurethral striated mus- cle, bulbocavernosus muscle, spinal cord, cerebral cortex or other). When recording spinal evoked responses, the sites of the recording electrodes should be specified according to the bony landmarks (e.g. L4). In cortical evoked responses the sites of the recording electrodes should be specified as in the International 10–20 system (6). The sampling techniques should be specified (single or multiple, unilateral or bilateral, ipsilateral or con- tralateral or other). (iii) Reference electrode position. (iv) Grounding electrode site: ideally this should be between the stimulation and recording sites to reduce stimulus artefact. Technical information (Also applicable to reflex latencies and evoked potential – see below.)

Appendix 2: ICS standardisation of terminology 1988 463 Specify (a) Electrodes (make and specifications). Describe separately stimulus and recording electrodes as below (i) design (e.g. needle, plate, ring, and configuration of anode and cathode where applicable) (ii) dimensions (iii) electrode material (e.g. platinum) (iv) contact medium (b) Stimulator (make and specifications) (i) stimulus parameters (pulse width, frequency, pattern, current density, electrode impedance in Kohms. Also define in terms of threshold e.g. in case of supramaximal stimulation) (c) Amplifier (make and specifications) (i) sensitivity (mV–␮V) (ii) filters – low pass (Hz) or high pass (kHz) (iii) sampling time (ms) (d) Averager (make and specifications) (i) number of stimuli sampled (e) Display equipment (make and specifications to include method of calibration, time base, full scale deflection in microvolts and polarity) (i) oscilloscope (f) Storage (make and specifications) (i) paper (ii) magnetic tape recorder (iii) microprocessor (iv) other (g) Hard copy production (make and specification) (i) chart recorder (ii) photographic/video reproduction of oscilloscope screen (iii) XY recorder (iv) other. Description of nerve Recordings are made from muscle and the latency of response of the conduction studies muscle is measured. The latency is taken as the time to onset, of the earli- est response. (a) To ensure that response time can be precisely measured, the gain should be increased to give a clearly defined takeoff point. (Gain set- ting at least 100 ␮V/div and using a short time base e.g. 1–2 ms/div). (b) Additional information may be obtained from nerve conduction stud- ies, if, when using surface electrodes to record a compound muscle action potential, the amplitude is measured. The gain setting must be reduced so that the whole response is displayed and a longer time base is recommended (e.g. 1 mV/div and 5 ms/div). Since the amplitude is proportional to the number of motor unit potentials within the vicin- ity of the recording electrodes, a reduction in amplitude indicates loss of motor units and therefore denervation. (Note: A prolongation of latency is not necessarily indicative of denervation).

464 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY 5.3 REFLEX Reflex latencies require stimulation of sensory fields and recordings from LATENCIES the muscle which contracts reflexly in response to the stimulation. Such responses are a test of reflex arcs which are comprised of both afferent and efferent limbs and a synaptic region within the central nervous sys- tem. The reflex latency expresses the nerve conduction velocity in both limbs of the arc and the integrity of the central nervous system at the level of the synapse(s). Increased reflex latency may occur as a result of slowed afferent or efferent nerve conduction or due to central nervous system conduction delays. GENERAL INFORMATION and TECHNICAL INFORMATION. The same technical and general details apply as discussed above under nerve conduction studies (see 5.2). Description of reflex Recordings are made from muscle and the latency of response of the latency measurements muscle is measured. The latency is taken as the time to onset, of the earli- est response. To ensure that response time can be precisely measured, the gain should be increased to give a clearly defined take-off point. (Gain setting at least 100 ␮V/div and using a short time base e.g. 1–2 ms/div). 5.4 EVOKED Evoked responses are potential changes in central nervous system neur- RESPONSES ones resulting from distant stimulation usually electrical. They are recorded using averaging techniques. Evoked responses may be used to test the integrity of peripheral, spinal and central nervous pathways. As with nerve conduction studies, the conduction time (latency) may be measured. In addition, information may be gained from the amplitude and configuration of these responses. GENERAL INFORMATION and TECHNICAL INFORMATION. See above under nerve conduction studies (see 5.2). Description of evoked Describe the presence or absence of stimulus evoked responses and their responses configuration. Specify (a) Single or multiphasic response. (b) Onset of response: defined as the start of the first reproducible poten- tial. Since the onset of the response may be difficult to ascertain pre- cisely, the criteria used should be stated. (c) Latency to onset: defined as the time (ms) from the onset of stimulus to the onset of response. The central conduction time relates to cortical evoked potentials and is defined as the difference between the latencies of the cortical and the spinal evoked potentials. This parameter may be used to test the integrity of the corticospinal neuraxis. (d) Latencies to peaks of positive and negative deflections in multiphasic responses (Fig. A2.6). P denotes positive deflections, N denotes nega- tive deflections. In multiphasic responses, the peaks are numbered

Appendix 2: ICS standardisation of terminology 1988 465 Figure A2.6 Multiphasic N52 N79 evoked response recorded from the cerebral cortex after 35 stimulation of the dorsal aspect of the penis. The recording _ shows the conventional labelling P44 1 μV of negative (N) and positive (P) deflections with the latency of P66 + each deflection from the point 50 msec of stimulation in milliseconds. consecutively (e.g. P1, N1, P2, N2 …) or according to the latencies to peaks in milliseconds (e.g. P44, N52, P66 …). (e) The amplitude of the responses is measured in ␮V. 5.5 SENSORY TESTING Limited information, of a subjective nature, may be obtained during cys- tometry by recording such parameters as the first desire to micturate, urgency or pain. However, sensory function in the lower urinary tract, can be assessed by semi-objective tests by the measurement of urethral and/or vesical sensory thresholds to a standard applied stimulus such as a known electrical current. General information (a) Patients position (supine, sitting, standing, other). Specify (b) Bladder volume at time of testing. (c) Site of applied stimulus (intravesical, intraurethral). (d) Number of times the stimulus was applied and the response recorded. Define the sensation recorded, e.g. the first sensation or the sensation of pulsing. (e) Type of applied stimulus (i) electrical current: it is usual to use a constant current stimulator in urethral sensory measurement – state electrode characteristics and placement as in section on EMG – state electrode contact area and distance between electrodes if applicable – state impedance characteristics of the system – state type of conductive medium used for electrode/epithelial contact. Note: topical anaesthetic agents should not be used. – stimulator make and specifications. – stimulation parameters (pulse width, frequency, pattern, duration, current density). (ii) other – e.g. mechanical, chemical. Definition of sensory The vesical/urethral sensory threshold is defined as the least current thresholds which consistently produces a sensation perceived by the subject during stimulation at the site under investigation. However, the absolute values will vary in relation to the site of the stimulus, the characteristics of the equipment and the stimulation parameters. Normal values should be established for each system.

466 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY 6 A CLASSIFICATION OF URINARY TRACT DYSFUNCTION 6.1 THE STORAGE The lower urinary tract is composed of the bladder and urethra. They form PHASE a functional unit and their interaction cannot be ignored. Each has two functions, the bladder to store and void, the urethra to control and convey. 6.1.1 Bladder function When a reference is made to the hydrodynamic function or to the whole during storage anatomical unit as a storage organ – the vesica urinaria – the correct term is the bladder. When the smooth muscle structure known as the m.detrusor urinae is being discussed then the correct term is detrusor. For simplicity the bladder/detrusor and the urethra will be considered separately so that a classification based on a combination of functional anomalies can be reached. Sensation cannot be precisely evaluated but must be assessed. This classification depends on the results of various objective urodynamic investigations. A complete urodynamic assessment is not necessary in all patients. However, studies of the filling and voiding phases are essential for each patient. As the bladder and urethra may behave differently dur- ing the storage and micturition phases of bladder function it is most use- ful to examine bladder and urethral activity separately in each phase. Terms used should be objective, definable and ideally should be applic- able to the whole range of abnormality. When authors disagree with the classification presented below, or use terms which have not been defined here, their meaning should be made clear. Assuming the absence of inflammation, infection and neoplasm, Lower urinary tract dysfunction may be caused by: (a) Disturbance of the pertinent nervous or psychological control system. (b) Disorders of muscle function. (c) Structural abnormalities. Urodynamic diagnoses based on this classification should correlate with the patients symptoms and signs. For example the presence of an unstable contraction in an asymptomatic continent patient does not war- rant a diagnosis of detrusor overactivity during storage. This may be described according to: (a) Detrusor activity (6.1.1.1). (b) Bladder sensation (6.1.1.2). (c) Bladder capacity (6.1.1.3). (d) Compliance (6.1.1.4). 6.1.1.1 Detrusor activity In this context detrusor activity is interpreted from the measurement of detrusor pressure (pdet). Detrusor activity may be: (a) Normal. (b) Overactive. Normal detrusor function During the filling phase the bladder volume increases without a significant rise in pressure (accommodation). No involuntary contractions occur despite provocation. A normal detrusor so defined may be described as ‘stable’.

Appendix 2: ICS standardisation of terminology 1988 467 Figure A2.7 Diagrams of Detrusor pressure (cm H2O) filling cystometry to illustrate: Detrusor pressure (cm H2O) (a) Typical phasic unstable detrusor contraction. (b) The gradual increase of detrusor pressure with filling characteristic of reduced bladder compliance. (a) Volume (mL) (b) Volume (mL) Overactive detrusor function Overactive detrusor function is charac- terised by involuntary detrusor contractions during the filling phase, which may be spontaneous or provoked and which the patient cannot completely suppress. Involuntary detrusor contractions may be pro- voked by rapid filling, alterations of posture, coughing, walking, jump- ing and other triggering procedures. Various terms have been used to describe these features and they are defined as follows. The unstable detrusor is one that is shown objectively to contract, spon- taneously or on provocation, during the filling phase while the patient is attempting to inhibit micturition. Unstable detrusor contractions may be asymptomatic or may be interpreted as a normal desire to void. The presence of these contractions does not necessarily imply a neurological disorder. Unstable contractions are usually phasic in type (Fig. A2.7A). A gradual increase in detrusor pressure without subsequent decrease is best regarded as a change of compliance (Fig. A2.7B). Detrusor hyperreflexia is defined as overactivity due to disturbance of the nervous control mechanisms. The term detrusor hyperreflexia should only be used when there is objective evidence of a relevant neurological disorder. The use of conceptual and undefined terms such as hypertonic, systolic, uninhibited, spastic and automatic should be avoided. 6.1.1.2 Bladder sensation Bladder sensation during filling can be classified in qualitative terms (see 3.1) and by objective measurement (see 5.5). Sensation can be classified broadly as follows: (a) Normal. (b) Increased (hypersensitive). (c) Reduced (hyposensitive). (d) Absent. 6.1.1.3 Bladder capacity See 3.1. 6.1.1.4 Compliance Compliance is defined as: ⌬V/⌬p (see 3.1). Compliance may change during the cystometric examination and is vari- ably dependent upon a number of factors including: (a) Rate of filling. (b) The part of the cystometrogram curve used for compliance calculation.

468 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY (c) The volume interval over which compliance is calculated. (d) The geometry (shape) of the bladder. (e) The thickness of the bladder wall. (f) The mechanical properties of the bladder wall. (g) The contractile/relaxant properties of the detrusor. During normal bladder filling little or no pressure change occurs and this is termed ‘normal compliance’. However at the present time there is insufficient data to define normal, high and low compliance. When reporting compliance, specify: (a) The rate of bladder filling. (b) The bladder volume at which compliance is calculated. (c) The volume increment over which compliance is calculated. (d) The part of the cystometrogram curve used for the calculation of compliance. 6.1.2 Urethral function The urethral closure mechanism during storage may be: during storage (a) normal (b) incompetent. (a) The Normal urethral closure mechanism maintains a positive urethral clos- ure pressure during filling even in the presence of increased abdominal pressure. Immediately prior to micturition the normal closure pressure decreases to allow flow. (b) Incompetent Urethral Closure Mechanism An incompetent urethral clos- ure mechanism is defined as one which allows leakage of urine in the absence of a detrusor contraction. Leakage may occur whenever intraves- ical pressure exceeds intraurethral pressure (Genuine stress incontinence) or when there is an involuntary fall in urethral pressure. Terms such as ‘the unstable urethra’ await further data and precise definition. 6.1.3 Urinary Urinary incontinence is involuntary loss of urine which is objectively incontinence demonstrable and a social or hygienic problem. Loss of urine through channels other than the urethra is extraurethral incontinence. Urinary incontinence denotes: (a) A symptom (b) A sign (c) A condition. The symptom indicates the patients statement of involuntary urine loss. The sign is the objective demonstration of urine loss. The condition is the urodynamic demonstration of urine loss. Symptoms Urge incontinence is the involuntary loss of urine associated with a strong desire to void (urgency). Urgency may be associated with two types of dysfunction: (a) Overactive detrusor function (motor urgency). (b) Hypersensitivity (sensory urgency).

Appendix 2: ICS standardisation of terminology 1988 469 Signs Stress incontinence: the symptom indicates the patient’s statement of Conditions involuntary loss of urine during physical exertion. ‘Unconscious’ incontinence. Incontinence may occur in the absence of urge and without conscious recognition of the urinary loss. Enuresis means any involuntary loss of urine. If it is used to denote incontinence during sleep, it should always be qualified with the adjec- tive ‘nocturnal’. Post-micturition dribble and Continuous leakage denotes other symptom- atic forms of incontinence. The sign stress-incontinence denotes the observation of loss of urine from the urethra synchronous with physical exertion (e.g. coughing). Incontin- ence may also be observed without physical exercise. Post-micturition dribble and continuous leakage denotes other signs of incontinence. Symptoms and signs alone may not disclose the cause of urinary incontin- ence. Accurate diagnosis often requires urodynamic investigation in addition to careful history and physical examination. Genuine stress incontinence is the involuntary loss of urine occurring when, in the absence of a detrusor contraction, the intravesical pressure exceeds the maximum urethral pressure. Reflex incontinence is loss of urine due to detrusor hyperreflexia and/or involuntary urethral relaxation in the absence of the sensation usually associated with the desire to micturate. This condition is only seen in patients with neuropathic bladder/urethral disorders. Overflow incontinence is any involuntary loss of urine associated with over-distension of the bladder. 6.2 THE VOIDING During micturition the detrusor may be: PHASE (a) acontractile 6.2.1 The detrusor (b) underactive during voiding (c) normal. (a) The acontractile detrusor is one that cannot be demonstrated to contract during urodynamic studies. Detrusor areflexia is defined as acontractil- ity due to an abnormality of nervous control and denotes the complete absence of centrally coordinated contraction. In detrusor areflexia due to a lesion of the conus medullaris or sacral nerve outflow, the detrusor should be described as decentralised – not denervated, since the periph- eral neurones remain. In such bladders pressure fluctuations of low amplitude, sometimes known as ‘autonomous’ waves, may occasion- ally occur. The use of terms such as atonic, hypotonic, autonomic and flaccid should be avoided. (b) Detrusor underactivity. This term should be reserved as an expression describing detrusor activity during micturition. Detrusor underactivity is defined as a detrusor contraction of inadequate magnitude and/or duration to effect bladder emptying with a normal time span. Patients may have underactivity during micturition and detrusor overactivity during filling.

470 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY 6.2.2 Urethral function (c) Normal detrusor contractility. Normal voiding is achieved by a volun- during micturition tarily initiated detrusor contraction that is sustained and can usually be suppressed voluntarily. A normal detrusor contraction will effect comlete bladder emptying in the absence of obstruction. For a given detrusor contraction, the magnitude of the recorded pressure rise will depend on the degree of outlet resistance. During voiding urethral function may be: (a) normal (b) obstructive – overactivity – mechanical. (a) The normal urethra opens to allow the bladder to be emptied. (b) Obstruction due to urethral overactivity: this occurs when the urethral clo- sure mechanism contracts against a detrusor contraction or fails to open at attempted micturition. Synchronous detrusor and urethral contrac- tion is detrusor/urethral dyssynergia. This diagnosis should be qualified by stating the location and type of the urethral muscles (striated or smooth) which are involved. Despite the confusion surrounding ‘sphincter’ terminology the use of certain terms is so widespread that they are retained and defined here. The term detrusor/external sphincter dyssynergia or detrusor-sphincter-dyssynergia (D.S.D.) describes a detrusor contraction concurrent with an involuntary contraction of the urethral and/or periurethral striated muscle. In the adult, detrusor sphincter dyssynergia is a feature of neurological voiding disorders. In the absence of neurological features the validity of this diagnosis should be questioned. The term detrusor/bladder neck dyssynergia is used to denote a detrusor contraction concurrent with an objectively demonstrated failure of bladder neck opening. No parallel term has been elaborated for possible detrusor/distal urethral (smooth muscle) dyssynergia. Overactivity of the striated urethral sphincter may occur in the absence of detrusor contraction, and may prevent voiding. This is not detrusor/sphincter dyssynergia. Overactivity of the urethral sphincter may occur during voiding in the absence of neurological disease and is termed dysfunctional void- ing. The use of terms such as ‘non-neurogenic’ or ‘occult neuro- pathic’ should be avoided. Mechanical obstruction: is most commonly anatomical e.g. urethral stricture. Using the characteristics of detrusor and urethral function during storage and micturition an accurate definition of lower urinary tract behaviour in each patient becomes possible. 7 UNITS OF MEASUREMENT In the urodynamic literature pressure is measured in cm H2O and not in millimeters of mercury. When Laplace’s law is used to calculate tension

Appendix 2: ICS standardisation of terminology 1988 471 Table A2.1 Quantity Acceptable unit Symbol Volume Millilitre ml Time Second Flow rate Millilitres/second s Pressure Centimetres of water1 ml sϪ1 Length Metres or submultiples Velocity Metres/second or submultiples cm H2O Temperature Degrees Celsius m, cm, mm m sϪ1, cm sϪ1 °C 1 The SI unit is the pascal (Pa), but it is only practical at present to calibrate our instruments in cm H2O. One centimetre of water pressure is approximately equal to 100 pascals (1 cm H2O ϭ 98.07 PA ϭ 0.098 kPa). in the bladder wall, it is often found that pressure is then measured in dyne cmϪ2. This lack of uniformity in the systems used leads to confusion when other parameters, which are a function of pressure, are computed, for instance, ‘compliance’, contraction force, velocity etc. From these few examples it is evident that standardisation is essential for meaningful communication. Many journals now require that the results be given in SI Units. This section is designed to give guidance in the application of the SI system to urodynamics and defines the units involved. The principal units to be used are listed below (Table A2.1). SYMBOLS It is often helpful to use symbols in a communication. The system in Table A2.2 has been devised to standardise a code of symbols for use in Table A2.2 List of symbols Basic symbols Urological qualifiers Value Pressure p Bladder ves Maximum max Urethra ura Volume V Ureter ure Minimum min Detrusor det Flow rate Q Abdomen abd Average ave External stream ext Velocity v Isovolumetric isv Time t Isotonic ist Temperature T Isobaric isb Length l Isometric ism Area A Diameter d Force F Energy E Power P Compliance C Work W Energy per unit volume e Examples: pdet,max ϭ maximum detrusor pressure; e.ext ϭ kinetic energy per unit volume in the external stream.

472 PHYSIOTHERAPY IN OBSTETRICS AND GYNAECOLOGY urodynamics. The rationale of the system is to have a basic symbol repre- senting the physical quantity with qualifying subscripts. The list of basic symbols largely conforms to international usage. The qualifying subscripts relate the basic symbols to commonly used urodynamic parameters. References 207–210. Eur Urol 1977; 3: 168–170. Scand J Urol Nephrol 1977; 11: 197–199. 1. Abrams P, Blaivas JG, Stanton SL, Andersen JT, Fowler CJ, 4. Bates P, Bradley WE, Glen E, Griffiths D, Melchior H, Gerstenberg T, Murray K. Sixth report on the Rowan D, Sterling A, Hald T. Third report on the standardisation of terminology of lower urinary tract standardisation of terminology of lower urinary tract function. Procedures related to neurophysiological function. Procedures related to the evaluation of investigations: Electromyography, nerve conduction micturition: Pressure flow relationships, residual urine. Br J studies, reflex latencies, evoked potentials and sensory Urol 1980; 52: 348–350. Eur Urol 1980; 6: 170–171. Acta Urol testing. World J Urol 1986; 4: 2–5. Scand J Urol Nephrol Jpn 1980; 27: 1566–1568. Scand J Urol Nephrol 1980; 12: 1986; 20: 161–164. 191–193. 5. Bates P, Bradley WE, Glen E, Melchior H, Rowan D, 2. Bates P, Bradley WE, Glen E, Melchior H, Rowan D, Sterling A, Sundin T, Thomas D, Torrens M, Turner- Sterling A, Hald T. First report on the standardisation of Warwick R, Zinner NR, Hald T. Fourth report on the terminology of lower urinary tract function. Urinary standardisation of terminology of lower urinary tract incontinence. Procedures related to the evaluation of urine function. Terminology related to neuromuscular storage: Cystometry, urethral closure pressure profile, units dysfunction of lower urinary tract. Br J Urol 1981; 52: of measurement. Br J Urol 1976; 48: 39–42. Eur Urol 1976; 2: 333–335. Urology 1981; 17: 618–620. Scand J Urol Nephrol 274–276. Scand J Urol Nephrol 1976; 11: 193–196. Urol Int 1981; 15: 169–171. Acta Urol Jpn 1981; 27: 1568–1571. 1976; 32: 81–87. 6. Jasper HH. Report to the committee on the methods of clinical examination in electroencephalography. 3. Bates P, Glen E, Griffiths D, Melchior H, Rowan D, Sterling Electroencephalography in Clinical Neurophysiology, A, Zinner NR, Hald T. Second report on the 1958; 10: 370–75. standardisation of terminology of lower urinary tract function. Procedures related to the evaluation of micturition: Flow rate, pressure measurement, symbols. Acta Urol Jpn 1977; 27: 1563–1566. Br J Urol 1977; 49:

473 Index A see also human immunodeficiency Anal canal 22, 23 (fig.) virus (HIV) Anal columns 22 Abdomen Anal cones, faecal incontinence 419–20 examination 406, 435 Active Birth Movement 105 Anal continence 386 gynaecological surgery 310, 325, Acupuncture, pain relief in labour Anal fissure 327 massage 182, 183 (fig.), 417 189 defaecation pain 395–6 muscles see abdominal muscles Acyclovir 46 postnatal 396 pain see abdominal pain Addictive drugs, pregnancy 125 Anal incontinence shape change during labour 58 Adrenaline (epinephrine), labour and causative factors 399–402 Abdominal hysterectomy see 63–4 accidents 400 hysterectomy, abdominal Age age 399 anal sphincter dysfunction Abdominal muscles 11–12, 12 (fig.) anal incontinence and 399 defaecation 388, 414 first time mothers 109 399–400 ‘brace and bulge’ 414 menopause 249 childbirth 400 during labour 54–5 sexuality 301–2 functional faecal incontinence exercise 152, 213, 214, 227, 325 AIDS 276–7 home 219 see also human immunodeficiency 401–2 gynaecological surgery 325, 327 liquid stool 401 postnatal 205 virus (HIV) straining 401 postnatal status 206–7 Alcohol surgery 400 see also individual muscles trauma 400 bowel dysfunction 410 definition 389 Abdominal pain 291–2, 291 (fig.) effect on continence 368 prevalence 390 in labour 62 (fig.), 160, 182, 183 (fig.) pregnancy 122–3 see also faecal incontinence irritable bowel syndrome (IBS) 393 Alpha fetoprotein (AFP) level 100 Anal plugs, faecal incontinence 419–20 pregnancy 160 Amenorrhoea 27, 288–9 Anal sphincter see also intra-abdominal pressure exercise effect 103 dysfunction 399–400 pregnancy sign 33 exercise 415–16 Abdominal pressure 437, 451 secondary 288–9 external 23, 386, 387, 388 Abdominal retraction 227 American College of Obstetricians internal 22, 386, 387, 388 Abscess(es) paradoxical contraction 389 and Gynecologists (ACOG Andropause syndrome 253 Bartholin’s glands 273 2002) 75 Anismus 389 breast, postnatal 243 Amniocentesis 101 Anococcygeal body 22 Abuse Amnion 30 Anorectal angle 386 associated with incontinence 334 artificial rupture 79, 198 defaecation 387 bowel dysfunction 391, 404 rupture (breaking of waters) 55–6 Anorectal dysfunction 383–425 violence in pregnancy 98 Amniotic fluid 30 associated pathologies 384 Accidents, anal incontinence 400 loss, sign of labour 55–6 definitions 384–90 Acquired immune deficiency screening during pregnancy 101 prevalence 390 Amniotic sac see amnion prevention 384 syndrome (AIDS) 276–7 Amniotomy, labour induction 79, 198 Anaemia in pregnancy 43 dilution anaemia 36

474 INDEX Anorectal dysfunction (contd) Antimotility drugs 413 back-care principles 143–6 skin care 420 Antispasmodics 413 examination 148–9 treatment 410–21 Anus 390–1 factors influencing 142–3 bowel retraining 411 Anxiety management 146–7 diet 410–11 prevention 143–6 medication 411–20 defaecation difficulties 397 previous pregnancies 147–8 physiotherapy 413–20 fathers 132–3 treatment 149–55 see also individual disorders irritable bowel syndrome (ISB) 394 see also posture pain during labour 60, 184 Bacterial infections 272, 274 Anorectal examination 406–7, 407 postnatal 233 Bartholin’s glands 10 (table) Apgar score 71–2, 72 (table) abscess 273 Aponeurosis 11 cyst 277, 278 Anorectal flap 387 (fig.) Arcus tendineus fascia of the pelvis marsupialisation 320 Anorectal function 384–8 Baths/bathing (ATFP) 8 baby, posture advice 219 abnormal see anorectal dysfunction Areola 12 warm 185 continence maintenance 386 first stage of labour 70 Anorectal manometry 408 pigmentation changes 38 perineal dysfunction/pain 223 Anorectal region 22–3 Aromatherapy, pain relief in labour 190 Bearing down urge 54–5, 175 Anorexia nervosa Artificial rupture of membrane (ARM) Bed mobility, gynaecological surgery defaecation difficulties 392 324–5 menstruation effect 27 79, 198 Bed wetting see nocturnal enuresis Anorgasmia 295 Association for Continence Advice Behavioural modification, lower Antenatal care 93–140 urinary tract dysfunction 445 aims 94 (ACA), guidelines for intimate Bicornuate uterus 15 care team 96–7 examinations 355 Bilateral salpingo-oophorectomy 311 early pregnancy 104 Association of Chartered endometriosis 283 emotional distress 109 Physiotherapists in Obstetrics Billings ovulation method 29 fatigue 109 and Gynaecology (ACPOG) Biofeedback lifestyle 109–10 xviii–xix constipation 416 neuromuscular control teaching Atrophic vaginitis 251–2 faecal incontinence 416–17 lower urinary tract dysfunction 445 111–13 B PFM assessment 357–60, 372–5 breathing 112–13 manometry 372–3 contrast method 112 Babies Birth canal, formation 55, 65 touch and massage 112 bathing, posture advice 219 Birthing pool 70–1, 190 visualisation and imagery 112 feeding Birth partner NICE guidelines 98 after caesarean section 238 massage 181 options 95–7 multiple births 239–40 role 166 preconceptual care 102–4 posture advice 217–18 Birth plans 197–8 relaxation 109–10, 112 (fig.) see also breastfeeding Birth weight, effects on labour 66 routine care 97–100 loss of 199–200 Bishop score 33, 53, 54 (table) booking visit 97–8 macrosomic, diabetes and 45 Bisphosphonates, osteoporosis screening 100–2 massage 220–1 treatment 263 acceptability 101–2 pre-term 200 Bladder 19–20 stress 109–10 suckling capacity 440–1, 452, 467 working during 110 difficulty 12 compliance volume 337, 440, 452, see also antenatal classes; midwives uterine contraction and 59, 79, Antenatal classes 104–19, xxii 84, 197 467–8 6-week course 128–9 cystometry see cystometry class reunion 130–1 ‘Baby blues’ 234 displacement 284 crash courses 127 Backache see back pain dysfunction see urinary criteria 105 Back care, pregnancy 106, 106 (fig.), ‘early bird’ classes 105–6, 126 incontinence education in back pain 143 107 (fig.) expression 446 environment 127–8 gynaecological surgery 325, 327 filling 336, 437–8 exercise in water 37 Back pain 227–8, 291–2, 291 (fig.) history xvii–xviii coping strategies 155 (fig.) neurophysiological evaluation planning 126–38 epidural anaesthesia and 195–6, 228 460–5 self-help strategies 131 low (lumbar) see low back pain see also parenthood classes postnatal 207, 242 non-physiological filling rate Antepartum haemorrhage (APH) 43–4 postural 154 437–8 pregnancy 142–9 assessment 147–9

Index 475 physiological filling rate 437 physical examination 405–7 alteration during 171 imaging 360–1 associated pathologies 384 contractions and 172–6 pain, definition 432 definitions 384–90 first stage 173–4 position 341 drug induced 384 pushing 176–7 pregnancy 41 patients at risk 335 second stage 176–7 pressure 336–7 prevalence 390 teaching techniques 172 prevention 384 transition stage 174–5 closure 337 skin care 420 neuromuscular control 112–13 factors contributing 337 treatment 410–21 Breech position 44, 74–5, 199 measurement 361–2 types 75 measurements during bowel retraining 411 Bristol stool chart 385 (fig.) diet 410–11 British Council for Cervical Cytology, micturition 457–8 medication 411–20 classification of smear results puerperium 85 physiotherapy 413–20 271 reflex triggering 446 see also individual disorders British National Formulary (BNF) 124 retraining 377 Bowel function 383–425 Bulbospongiosus muscle 10 sensation 430, 438, 451, 467 abnormal see bowel dysfunction Bulking agents, bowel dysfunction 412 urine storage 336–7, 339–41, 466–8 anatomy 22–23 Burning vulva syndrome see defaecation see defaecation vulvodynia detrusor function 466–8 normal 384–8 urethral function 468 storage 386–7 C voiding (emptying) see micturition Bowel habits wall, stretch receptors 339 diary 402–3, 403 (fig.) Caesarean section 81–4, 199 Bladder diary 352–4, 353 (fig.), 434 questionnaires 402–4 classical 82 Bladder outlet obstruction 444 Brachial plexus pain, pregnancy 156 ectopic pregnancy and 84 Bladder pain syndrome, definition 432 Brachytherapy 314 elective 197 Blastocyst 29 Braxton Hicks contractions 36, 56 breech presentation 75 Bleeding breathing 173 indications 81–2 breakthrough 290 see also uterine contractions procedure 83 dysfunctional uterine bleeding Breakthrough bleeding 290 emergency, indications 82 Breast(s) 12–13, 13 (fig.) epidural anaesthesia 193, 196 (DUB) 291 antenatal care 133–4, 134 increasing rates xxi during labour 43–4 awareness 270 multiple births 125 postmenopausal 249 blood supply 13 Pfannenstiel (bikini line) 82, 83 see also haemorrhage growth 12 postnatal care 237–9 Blood group, antenatal tests 100 increase in size 134 exercises 238 Blood, in stools 394 menopause 13 feeding 238 Blood pressure milk production 12, 85–6 massage 238 labour, effect on 64 see also breastfeeding physiotherapist’s role 237–9 measurement postnatal 207 posture 238 pregnancy effects 38 wound healing 238 labour 70 problems, postnatal 231–2, 243 postoperative complications pregnancy 98 Breast abscess 243 83–4 pregnancy Breast cancer effects on 37 HRT and 255, 260 Caffeine pregnancy-induced pregnancy 44 bowel dysfunction 404, 411 Breast engorgement 231–2 incontinence 368 hypertension 48–9 Breastfeeding 86, 208–10 pregnancy 120, 122 Blood supply antenatal care 133–4 antenatal classes 129 Calcitonin, osteoporosis treatment 263 anorectal region 23 older mothers 134 Calcitriol, osteoporosis treatment 264 breasts 13 posture advice 134–5, 217–18, 217 Calcium urethra 21 Blood tests, antenatal 99–100 (fig.), 232 osteoporosis 258 Blood volume, increase in pregnancy problems 209, 231–2 pregnancy 120 suckling difficulty 12 Calcium channel blockers, anal fissure 36 weight loss assistance 119 Body image WHO recommendations 133–4 396 Breathing 170–7 Calorie intake cancer and 303 labour 172 postnatal 205, 220, 234 defaecation difficulties 392 Body mass index (BMI) 97, 119 pregnancy 114, 119 Booking visit 97–8 Bowel dysfunction 383–425 assessment 402–10 history 402–5 investigations 408–10

476 INDEX Cancer malignancy 279–80 Combined oral contraceptive (COC), benign tumours 277 pregnancy effects 16, 33 endometriosis 282 body image 303 suspensory ligaments 18 (fig.) breast 44, 255, 260 ‘Changing childbirth’ xxi–xxii Compressor urethrae 21 cervical 279–80 Chest infection, postoperative 328 Concentric needle electromyography endometrium 280 Chignon 81 malignant tumours 277 Childbirth see labour 409 ovary 280–1 Chlamydia trachomatis 274–5 Constipation 384, 389 sexuality after 303 Chloasma (mask of pregnancy) 38 vulva 277–8 Chondromalacia patellae, pregnancy biofeedback therapy 416 consequences 398–9 Candida albicans 272 159 diastasis recti abdominis 225 Capacitation 15 Chorion 29 elderly 398 Carbon dioxide, in labour 171 Chorionic villus sampling (CVS) 29, irritable bowel syndrome (IBS) 393 Carcinoma massage 417–18 100, 101 optimal defaecation position 388, endometrium 280 Circulatory system fallopian tubes 280 388 (fig.) Cardiac decompensation, labour 45 disorders in pregnancy 157–9 postnatal 225 Cardiac disease 44–5 haemorrhoids 158 pregnancy 396 Cardinal (transverse cervical) muscle cramps 158–9 prevalence 390 thrombosis/thromboembolism psychological problems 399 ligaments 18 159 treatment 411–13 Cardiotocograph (CTG) 70 varicose veins 157 workplace 393 Cardiovascular disease (CVD) vulval varicose veins 157–8 Consultant obstetric units, antenatal incidence 255 exercises during pregnancy 108–9 care 96 postmenopause 254, 255 gynaecological surgery 324 Consultants, antenatal care 96 pregnancy 44–5 reproductive tract 17 Continence 333 protection 255 Climacteric 249–68 Cardiovascular system adverse effects 251 advice 368 demands during maternal exercise age of occurrence 249 neurological control 339–41, 340 hormone changes 250, 253 114 hot flushes 251 (fig.) labour effects 64, 170–1 neurological symptoms 253 problems see incontinence pregnancy effects 36–7 organ atrophy 250, 251–2 Continence Foundation xx–xxi Carpal tunnel syndrome physical symptoms 251–2 guidelines for continence care xx postnatal 243 sexuality 253–4, 301–2 Contraception, postnatal advice 210 pregnancy 155–6 skin changes 252 Contractions see uterine contractions Catecholamines, labour and 64 terminology 250 (fig.) Cooley’s anaemia, pregnancy 49 Catheter, cystometry 361–2 urinary disorders 252 Coronary artery disease, HRT 255 Catheterisation, lower urinary tract vaginal changes 250 Corpus luteum 14 hormone production 29 dysfunction 445–6 soreness 251–2 Cot death 201 Cauphyllum 190 see also menopause Coulevaire uterus 77 Centers for Disease Control and Clomifene, preconceptual care 103 Cramp, exercises for during pregnancy Coccydynia 142, 153–4, 228–9 Prevention and the American physiotherapeutic measures 228 108–9 College of Sports Medicine Coccygeus (ischiococcygeus) 7 Cystitis 344 (CDC-ACSM) 42 Cognitive performance, oestrogen 253 Cephalic presentation 54 Collagenous tissue honeymoon 347 Cephalopelvic disproportion (CPD) breakdown during pregnancy 42, Cystocoele 284, 285, 285 (fig.) 77, 198 Cervical dystocia 77, 198 143, 147 micturition difficulties 348 Cervical ligaments, transverse 18 uterus 35 surgical treatment 314 Cervicitis 274–5 Colon, defaecation 387 Cystometry 361–2, 450–2 Cervix 16 Colonic transit studies 408 definitions 451–2 benign tumour 278–9 Colporrhaphy 314 disadvantages 362 cytology 270–1 anterior 314–15 filling 437–42 dilation during labour 33, 54, posterior 315–16 risks/complications 315–16 bladder capacity 440–1 55 (fig.) sacral 316 bladder compliance 440 assessment 58–9 Colposcopy 320 bladder sensation 438 pain 60 Colposuspension 317–18 detrusor function 438–40 disorders 274–5 urethral function 441–2 erosion 274 specify 451 technique 451 Cystoscopy 364 Cystourethrocoele 285

Index 477 Cystourethroscopy 364 Diarrhoea Edinburgh postnatal depression scale Cysts 277–83 irritable bowel syndrome (IBS) 393 132 treatment 420–1 Bartholin’s glands 277, 278, 320 Education, preparation for labour 167 ovary 280 Diastasis recti abdominis 43, 206, 206 Educator 358–9, 359 (fig.) physiotherapy 283 (fig.), 242 Egg (ovum) 14 vagina 278 Elderly assessment 226–7 D constipation 225 constipation 398 exercises 227 defaecation difficulties 397–8 Decidua 15 re-education 227 faecal incontinence 390 Deep vein thrombosis (DVT) Dick-Read, Grantly Dr xviii sexuality 302 Diet Electrical stimulation, lower urinary postnatal 230–1 incontinence management 347 postoperation complications 328 irritable bowel management 394 tract dysfunction 445 Defaecating proctogram 409 pregnancy 119–26 Electromyography (EMG) 373–5 Defaecation 387–8 difficulties foods to avoid 121–3 computerised 373–4 nutrients 120–1 concentric needle 409 elderly 397–8 Dilatation and curettage (D&C) 320 incontinence 363–4 factors contributing 390–8 Dilution anaemia (physiological motor conduction tests 364 see also constipation anaemia of pregnancy) 36 muscle activity 8–9 ignoring call 393 Discharge advice, gynaecological PFM assessment 358, 359 optimal position 388, 388 (fig.) surgery 329–30 single fibre density 363 technique 413–15 Displacement urinary tract 460–2 abnormal 390–1 anterior compartment 285 vaginal cones 374–5 workplace constipation 393 middle compartment 286–7 see also faecal incontinence physiotherapy 287 considerations 375 Dehydration 39 posterior compartment 287 selection of appropriate 374 during labour 65 types 285 (fig.) treatment sessions 374–5 Dementia see also genital prolapse Electrophysiological tests, defaecation difficulties 398 Doula, support during labour 70 incontinence 363–4 oestrogen 253 ‘Dowager’s hump’ 256 Embryo 30 Depression, defaecation difficulties Down’s syndrome, screening for 100, Emotional distress 74 397 101 antenatal period 109 Dermatology see skin Drinking, recommendations during pain, effect on 62 Descent of foetal head 34 (fig.) labour 64–5 postnatal 233–4 Descending perineum syndrome 225, Drug-induced diarrhoea 401 see also maternal distress 389 Drugs of abuse, pregnancy 125 Emotional vulnerability, postnatal Detrusor 19 Dysaesthetic vulvodynia 298–9 209–10 function 466–7 Dyschezia 389 Endoanal ultrasonography (EAUS) 409 filling cystometry 438–40 Dysfunctional uterine bleeding (DUB) Endocrine system, pregnancy effects micturition 443, 469–70 291 32–3 overactivity see urinary Dysmenorrhoea 289 see also hormones Dyspareunia 240–1, 296–8 Endometriosis 281–3 incontinence treatment 298 aetiology 282 pressure 437, 451 types 296 fertility 283 sphincter dyssynergia 444 Dysuria 343 investigations 282 Diabetes mellitus prevalence 281 pregnancy and 45 E symptoms 281 pregnancy-related (gestational) treatment 282–3 ‘Early bird’ antenatal classes 105–6, Endometritis 275 41, 46 126 Endometrium 15 Diaphragm ablation 320 Eating disorders, defaecation carcinoma 280 displacement during pregnancy difficulties 391 Endopelvic fascia 5, 6, 8 38 Energy expenditure, in pregnancy 39 Eating, recommendations during Enterocoele 286 in labour 54–5 labour 64–5 Entonox 190–1 Diaries Enuresis 342, 430 Eclampsia 48–9 Environmental factors, faecal bladder diary 352–4, 353 (fig.) Ectopic pregnancy 15, 45 incontinence 402 bowel habit diary 402–3, Enzymes, prelabour role 53 following caesarean section 84 403 (fig.) food diary 405 (fig.)

478 INDEX Epidural anaesthesia 185, 192–6 liquid stool 401 Foetal hypoglycaemia, maternal advantages 192–3 passive soiling 389 exercising 114 back pain 195–6, 228 prevalence 390 caesarean section 193, 196 skin care 420 Foetal hypoxia 73–4 complications 193–5 treatment 413, 415, 416–7, 418 Foetal malformations, maternal foetal effects 195 see also anal incontinence; anorectal haematoma 195 temperature and 115 maternal position and 67 dysfunction; bowel Foetal movements 99 pre-booked 165 dysfunction technique 193 The Faecal Incontinence Quality of cessation 99 Life Scale (FIQLS) 404 Foetal positions, labour 53–4 Episiotomy 65–6, 78, 80, 199 Faecal softeners 413 Foetal thorax, compression 64 anal incontinence 400 Fallopian tubes 15 Foetus 30 position 80 (fig.) carcinoma 280 ectopic pregnancy 15, 45 descent of head 34 (fig.), 63 Erectile dysfunction (ED) 253 infections 275 development see foetal growth Ergometrine 196 surgery 313, 316 drug sensitivity 30 Estimated date of delivery (EDD) 30 False labour 36 Exercise Faradism 364 pethidine effects 191–2 Fathers 132–3 HIV transmission 46–7 caesarean section and 238 Fatigue intrauterine death 46 foot, DVT prevention 231 postnatal 232–3 labour effects 63–5 gentle, during labour 70 pregnancy 109, 161 macrosomic 45 postnatal 210–11 Fat, increase during pregnancy 39 maternal exercise effects 115–16 Female anatomy 1–25 maternal hyperventilation 171 community classes 220 Ferguson’s reflex 71, 194 positioning 53–4 educational principles 214–16 Fertility home exercises 219–20 endometriosis 283 breech see breech position return to sport 220 problems see infertility head, engaged 34–5 preconceptual 102 Fibre 39, 410 unstable/transverse lie 49–50 during pregnancy 36, 103, 113–19, defaecation difficulties 392–3 premature delivery 31 pregnancy requirement 121 sex detection 101 132 Fibroareolar lateral ligaments 20 TENS effect 187–8 benefits 118 Fibroids 45–6, 278–9 see also entries beginning foetal contraindications 116, 116 pregnancy 160 Folic acid 102 Fibromyoma 278 Food diary 405 (fig.) (table) ‘Fight or flight’ response 63–4, 110 Foot exercise, DVT prevention 231 foetal risks 115–16 Fish oils, pregnancy 120 Forceps delivery 199 guidelines 116–18 Fluid incontinence risk 224 low back pain 150 input/output during labour 70 labour interventions 80–1 physiological effects 114–15 intake 410 unassisted vaginal birth vs. 211–12 pre-term labour 115–16 defaecation difficulties 392 Fracture 256–7 signs for medical review 117 retention, pregnancy 37 risk reduction 259–60 walking 42 Fluoride, osteoporosis treatment 264 Frequency volume chart (FVC) 352–4, water based 36, 37, 118–19 Fluoroscopic evaluation, rectal 353 (fig.), 434 External anal sphincter (EAS) 23 emptying 409 Fundal height defaecation 387, 388 Foetal adrenal hormones, labour antenatal care 98–9 resting pressure 386 induction 57 gestational age vs. 34 (fig.) External cephalic version (ECV) 44 Foetal alcohol syndrome (FAS) 123 Fungal infections 272, 274 Extremely low birth weight infants Foetal distress (ELBW) 31 labour complications 73–4 G maternal exercising 115 F prolonged labour 59 Gardnerella vaginalis 274 Foetal growth 29–31 Gartner’s ducts, infection 273 Faecal impaction 398, 401 fundal height 34 (fig.), 98–9 Gastric reflex, pregnancy 39 Faecal incontinence 8, 224–5, 242, 389 maternal exercising, effect on 115 Gastrocolic reflex 386 patterns 31 (table) Gastrointestinal system assessment 402–10 Foetal heart 36 history 402–5 monitoring 70, 73, 99 labour effects 64–5 investigations 408–10 pregnancy 39 physical examination 405–7 General Medical Council Standards biofeedback therapy 416–17 Committee 406 elderly 390 General practitioner (GP), antenatal functional 401–2 care 96

Index 479 Genetic counselling, preconceptual posture and backcare 325, 327 diseases associated 260 care 102 preoperative issues 322–6 implant 261–2 long-term risks 254 Genital assessment 435 assessment 322–3 nasal spray 262 Genital herpes, pregnancy 46 instruction/preparation 323–6 oral 261 Genital muscles, external 6 patient discussion 326 osteoporosis treatment 260–2 Genital organs, external 10, 11 (fig.) treatment 326 progestogen administration 262 Genital prolapse 283–7 psychological aspects 321–2 prolapse 284 radiotherapy 314 skin 252 anterior compartment 285 repair 314–16 topical (vaginal) 262 HRT 284 respiratory system 323–4 transdermal 262 hysterectomy 284 rest 328 Hormones middle compartment 286 stress incontinence 317–20 joint laxity effects 41–2 physiotherapy 287 terminology 320 measurement during pregnancy posterior compartment 286 wind pain 326 surgery see gynaecological surgery 100 Genital tract, infection susceptibility 17 H menopause Genitourinary dysfunction/pain Haemoglobin monitoring, antenatal changes 250–3 224–6, 431–3 care 99 replacement see hormone Gestational diabetes mellitus 41, 46 Giggle incontinence 347 Haemoglobinopathies replacement therapy Gilliam’s ventrosuspension 316 pregnancy 49 (HRT) ‘Glazer’ protocol 299 testing in antenatal care 100 menstruation control 27, 28 (fig.), Glycerol trinitrate (GTN) cream, anal 29 Haemorrhage preconceptual treatments 103 fissure 395 antepartum 43–4 pregnancy 32–3 Gonorrhoea 273, 274 labour complications 77, 196 pain role 143 Gravitational oedema, puerperium 88 postpartum 87 see also individual hormones Gravity (centre of), pregnancy effects Hot flushes 251 Haemorrhoids HRT see hormone replacement 42–3 anal incontinence 401 therapy (HRT) Gynaecological conditions 269–308 ice therapy 231 Human chorionic gonadotrophin postnatal 231 (HCG) 29 backache/abdominal pain 291–2, pregnancy 158 morning sickness, role 30 291 (fig.) Human immunodeficiency virus Hair loss, postnatal 243 (HIV) 276–7 common disorders 271–5 Hammock hypothesis 6 (fig.), 8 pregnancy 46–7, 99 cysts and new growths 277–83 Hartmann’s solution 193 transmission 276 emotional/psychological The Health Committee (Maternity Human papilloma virus (HPV) 273 implications 302–3 Services 1992), water births 190 Hyperemesis gravidarum 39 infections 271–7 Health professionals, labour Hyperglycaemia, maternal 45 Hypertension, pregnancy-induced physiotherapy 276 preparation 165 48–9 physical check-up 270–1 Health visitor, role xix Hyperventilation 171, 171 (table), 173 physiotherapist attitudes 269 Health Visitors’ Association (HVA) xix Hypnosis, pain relief in labour 189 physiotherapy 276 Heartburn, pregnancy 39, 161–2 Hypogastric nerve 20 screening 269 Heart, pregnancy and 36–7 Hypogastric plexus, autonomic 22 surgery for see gynaecological HELLP syndrome 48 Hypoglycaemia, maternal exercising Herpes genitalis 273 114 surgery Herpes simplex virus, pregnancy 46 Hypomenorrhoea 288 Gynaecological health 269–71 Hilum 18–19 Hypotension, pregnancy 37 Gynaecological surgery 309–32 HIV see human immunodeficiency Hysterectomy 309–13, 320 abdominal 310–12 bed mobility 324–5 virus (HIV) postoperative condition 311 circulatory system 324 Homan’s signs 230 procedure 310–11 excision 309–13 Home births 95–6 risks/complications 312 physiotherapy 322–8 endometriosis 283 UK rates 95 indications 309–10 abdominal muscle exercise Homeopathy, pain relief in labour 190 menopause 251 325, 327 ‘Honeymoon cystitis’ 347 Hormone replacement therapy (HRT) mobilisation 327–8 pelvic floor muscle exercise 13, 251 administration 261–2 325, 326–7 benefits 255 postoperative issues 326–8 complications 328 discharge advice 329 leaving hospital 328 lifelong advice 330

480 INDEX Hysterectomy (contd) Injuries, pregnancy and exercise 42 complications 73–9 number performed 310 Insomnia, pregnancy 161 breech birth see breech position ovarian failure 251 Intercostal arteries 13 cephalopelvic disproportion 77 prolapse following 284 Interferential therapy (IT), contracted pelvis 77 route 310 failure to progress 73 subtotal 311 incontinence treatment 375 foetal distress 73–4 vaginal 312–13 Internal anal sphincter (IAS) 22 haemorrhage 77, 196 LAVH 312–13 incoordinate uterine activity postoperative condition 312 defaecation 387, 388 76–7 procedure 312 resting pressure 386 knotted cord 76 risks/complications 312 International Consultation on malposition 75–6 Wertheim’s 311 malpresentation 74 Incontinence Questionnaire maternal distress 74 Hysteroscopy 320 (ICIQ) 360 multiple births 78 International Continence Society (ICS), perineal trauma 78–9 I terminology 342, 344 placental abruption 44, 77 lower urinary tract function (1988) placenta praevia 44 Ice therapy prolapsed cord 76 haemorrhoids 231 449–72 retained placenta 79 perineal dysfunction/pain 222–3 lower urinary tract function (2002) see also specific complications Iliac arteries 17 427–47 coping strategies 184 Iliococcygeus 5–6, 7, 8 International Society for the Study of drive angle 58, 58 (fig.) Imaging, incontinence assessment 364 duration 66 Incontinence 334 Vulvar Disease (SSVD), dyspareunia 297 classification 272 false 36 definitions 334, 435 Intra-abdominal pressure 337, 361, fear/embarrassment 175 diet 347 386, 388 first stage 54 double 334 see also bearing down, straining extra-urethral 435 Intracytoplasmic sperm injection active 58 faecal see faecal incontinence (ICSI) 103 breathing 170–4 functional activity 378–9 Intrauterine death 46 coping strategies 129 imaging 364 Intrauterine growth retardation latent 58 prevention 335 (IUGR) 47, 98–9 management 70–1 urinary see urinary incontinence foetal AIDS 46 pain 54, 60–1 Infants see babies Intravesical pressure 437, 451 position 66–7, 179 (fig.) Infection(s) 271–7 In vitro fertilisation (IVF) 103 variations 198–9 anal incontinence 401 Iron, pregnancy 120 foetal head, descent of 34 (fig.), 63 bacterial 272, 274 Irritable bowel syndrome (IBS) 393–4 foetal physiology, effect on 63–5 differential diagnosis, importance Ischiocavernosus muscle 10 foetal position 53–4 Ischiococcygeus (coccygeus) 7 history xix–xx 299 Isthmus 57 home births 95–6 fallopian tubes 275 interventions 79–84, 198 fungal 272, 274 J after effects 236–40 Gartner’s ducts, 273 amniotomy 79, 198 genital tract, susceptibility 17 Joint laxity in pregnancy 4, 41–2, 150 caesarean section see caesarean organisms 272–3, 274 parasitic 273 K section physiotherapy 276 episiotomy see episiotomy postoperation complications 328 Kidneys 18–19 forceps see forceps delivery puerperal 88 Kielland forceps 81 oxytocin 79 urinary see urinary infections Kneeling, puerperium posture 217 prostaglandins 79 uterine 275 vacuum extraction (ventouse viral 273 L vulval 271–3 delivery) 81, 199, 211–12 see also specific infections Labial lacerations 78, 199 management (normal labour) Infertility 103–4, 293 Labour 53–91 caesarean section, after 83 68–73 primary 293 ‘after-pains’ 229–30 recording progress 68, 70 secondary 293 anal incontinence 400 massage see massage in vitro fertilisation (IVF) 103 anteversion 58 maternal physiology, effect on 63–5 bear down urge 54–5, 175 maternal position during 66–8 bleeding during 43–4 see also posture, labour

Index 481 mechanics 63 Laparoscopic assisted vaginal genitourinary pain and syndromes pain 59–63, 187 hysterectomy (LAVH) 312–13 432–3 anxiety 60, 184 Laparoscopic colposuspension 318 signs 428, 434–6 causes 60–3 Laparoscopy 320 measuring frequency and control see pain relief Laparotomy 320 severity 434–5 coping strategies 63 Laplace’s law 470–1 pad testing 436 zone change 62 (fig.), 183 (fig.) Large loop excision of the physical examination 435–6 physical/physiological changes transformation zone (LLETZ) symptoms 433 53–6 313 treatment 445–6 pelvic floor 65–6 Laxatives 401, 411 perineum 65–6 abuse 392 behavioural modification 445 positioning in labour 66–8, constipation 412 biofeedback 445 osmotic 412 bladder expression 446 177–81, 178 (fig.), 179 Legal cases, PMT 290 bladder reflex triggering 446 (fig.), 180 (fig.) Let-down reflex 86, 209 catheterisation 445–6 prelabour 36, 53–4 Levator ani muscles 5–6 electrical stimulation 445 preparation for 126–38, 165–203 muscle fibres 8–9 pelvic floor muscle training 445 birth plans 197–8 sub division 8 see also urinary incontinence breathing see breathing Libido loss 235–6 Lower urinary tract symptoms 428, education 167 Lidocaine 78 429–33 relaxation see relaxation Lifelong advice, gynaecological associated with pelvic organ ‘tool kit’ of coping skills surgery 320 166–7 Lifestyle prolapse 431 pre-term 31, 200 antenatal period 109–10 associated with sexual intercourse maternal exercising and 115–16 changes, parenthood 132 process of normal 56–68 Lifting, pregnancy 146 431 prolonged 66 gynaecological surgery 329 pain 431–2 defaecation difficulties 397 Ligament(s) post micturition 431 pushing 176 postnatal damage 206–7 storage 429–30 rest after 86–7 reproductive tract 17–18, 18 (fig.) voiding symptoms 430–1 second stage 54–5 see also individual ligaments Lumbar lordosis 4, 42, 142 assistance 80–1 Linea alba 227 Lying down breathing 176–7 Listeria, pregnancy 121 postnatal posture 214–15, 216–17 contractions 59 Liver (dietary), pregnancy 122 pregnancy 143–4 descent 59 Lochia 85 Lymphatic system, reproductive management 71–2 Low back pain 228 maternal positioning 71 pregnancy 149–50 tract 17 pain 61 exercise programme 150 perineal 59 TENS and 149 M position 67 treatment 149–50 positioning 180 (fig.) Lower urinary tract Mackenrodt’s ligaments 18 variations 199 abnormal function see lower Macrosomic babies, diabetes and 45 signs of 55–6, 129 Magnetic resonance imaging (MRI), third stage 55 urinary tract dysfunction labour preparation 196–7 normal function 336–42 bowel dysfunction 409 management 72–3, 196–7 terminology Male sexual dysfunction 253–4 position 68 Manchester repair 316 variations 199 International Continence Manometry 372–3 transition stage, breathing 174–5 Society (1988) 449–72 Marsupialisation of Bartholin’s cyst trial of 77 uterine retraction 15 International Continence 320 variations 198–9 Society (2002) 427–47 Mask of pregnancy (chloasma) 38 warm bath and 70, 185 Massage water births 95 urine storage evaluation 450–6 Lactation 12, 85–6 Lower urinary tract dysfunction 342–3 baby 220–1 puerperium 85–6 caesarean section 238 see also breastfeeding classification 466–70 constipation 417–18 Lactiferous ducts 12 storage phase 466–9 history xvii Lactiferous sinus 12 voiding phase 469–70 ice cube 223 during labour 180–4 clinical assessment 450 frequency/volume charts 450 abdomen 182, 183 (fig.) history 450 back 181–2, 181 (fig.), 182 (fig.) physical disease 450 legs 182 perineal 182–4

482 INDEX Mastitis, postnatal 243 neurophysiological 460–5 Multiple sclerosis, pregnancy 44 Maternal alkalosis 64 pressure flow relationships Muscle(s) Maternal apnoea 171 Maternal dehydration 39 458–9, 458 (fig.), 459 (fig.) increased load on during Maternal distress urethral pressure 459 pregnancy 43 urinary flow 456–7, 457 (fig.) labour 74, 184–5 flow rate 338, 338 (fig.) postnatal condition 206–7 related thoughts, pain increase stopping 339 strengthening in pregnancy 145–6 frequency 160, 342, 345, 429 see also individual muscles 62 frequency/volume chart (bladder Muscle cramps, pregnancy 158 Maternal fatality 93–4 Muscle fibres diary) 352–4, 353 (fig.) levator ani muscles 8–9 pre-eclamptic toxaemia 49 collection 352 type I 9 UK rate 94 results 354 type II 9, 10 (table) Maternal hyperglycaemia 45 hesitancy 343 uterus 35–6 Maternal hyperventilation 36 increased daytime frequency 342–3 Musculoskeletal system Maternal serum screening 100 during labour 70 assessment 147–9 ‘Maternity blues’ 234 lower urinary tract symptoms 431 bad posture 217–19 Maternity leave 233 neurological control 341 pain 156 McGill pain questionnaire 60, 61 normal desire 343 pregnancy effects 41 pain scores 62 (table) pelvic floor 338–9 trauma during maternal exercise 114 Medications during pregnancy position 338 Myomectomy 313 privacy 338 Myometrium 15 124–5 residual urine 459–60 Megacolon 389, 394–5 stream 343 N Megarectum 389, 394–5 timed/prompted 377–8 Menarche 288 urethral function 443, 470 Naegele’s rule 30 Mendelson’s syndrome 64 urgency 343 Nappy changing, posture advice Menopause treatment 368 Midwives 218–19, 218 (fig.) associated disease 254 antenatal care 96 National Childbirth Trust (NCT) 105 breast cancer 255 home births 95–6 National Institute for Clinical cardiovascular 255 independent 97 osteoporosis see osteoporosis pain management 185 Excellence (NICE), guidelines stroke 255 postnatal care 208 for antenatal care 98 puerperium care 87 National Health Service (NHS), role in breast 13 role xix antenatal care 95 defined 249 shortage xxi Nausea in pregnancy 39, 162 dyspareunia 297 TENS 189 HCG role 30 HRT see hormone replacement Midwives and Health Visitors Neisseria gonorrhoeae 274 (Midwives’ Amendment) Rule Neonatal herpes 46 therapy (HRT) 1986 189 Neonates see babies non-HRT drug therapy 263–4 Milk ejection reflex 86, 208 Nerve compression syndromes, premature 293–4 Miscarriage 200 pregnancy 155–7 see also climacteric caesarean section, after 83 Nerve supply Menorrhagia 288, 291 Mitchell, Laura xviii anorectal region 23 Menstrual cycle 27–9, 28 (fig.) Mitchell method of physiological pelvis 17 cognitive ability 290 relaxation 109, 111–12, 168, xviii Nervous system defaecation difficulties 395 Monilial infection, differential labour pain 60–1, 61 (fig.) disorders 287–91 diagnosis 299 pregnancy effects 40 hormone effects 28 (fig.) Montgomery’s tubercles 12, 38 Neural tube defects (NTDs), screening physiological changes 15 Morning sickness 39, 162 100 premenstrual tension (PMT) 290 excessive 39 Neurogenic detrusor overactivity 439 human chorionic gonadotrophin Neurological complications legal cases 290 defaecation difficulties 395 Meralgia paraesthetica, pregnancy role 30 epidural anaesthesia 195 Morula 29 Neurological control 156–7 Mucoid show 55, 57 continence 339–41, 340 (fig.) Methoxyflurane (Penthrane) 190 Multiple pregnancy 47, 125 voiding 341 Micturition 336, 337–9 Neuromuscular control, teaching labour complications 78 111–13 cycle 336, 336 (fig.), 434 postnatal complications 239–40 urodynamic investigation 437–42 see also cystometry detrusor function 443, 469–70 difficulties 348–9 evaluation procedures 456–60 bladder pressure 457–8

Index 483 Neuromuscular stimulation, anorectal faecal incontinence 413 epidural anaesthesia see dysfunction 418 see also hormone replacement epidural anaesthesia Neurophysiological evaluation, therapy (HRT) homeopathy/aromotherapy urinary tract 460–5 Oligohydramnios 30, 47 190 Oligomenorrhoea 288, 289 Neuropraxia 224 Omega-3 fatty acids, pregnancy hypnosis 189 Neville Barnes’ forceps 81 pethidine 191–2 Nicotine, bowel dysfunction 404 120 TENS see TENS Nightmares, pregnancy 161 Oophorectomy 313 water 190 Night sweats 251 Orgasm, dysfunction 295 postnatal 209 Nipple 12 Osmotic laxatives 412 advice 213 Osteoporosis 256–64 Paper towel test 355 inverted 12 Paracetamol, pregnancy 124 sore and cracked 232 calcium 258 Paradoxical anal sphincter contraction stimulation, uterine contraction development 256 389 diagnosis 258 Parasitic infections 273 and 59 exercise 259–60 Parathyroid hormone (PTH), Nitrous oxide, labour 190–1 fractures 256–7 osteoporosis treatment 263–4 Nocturia 342, 429 Parenthood classes 126–38, xx risk reduction 259 lifestyle changes 132 pregnancy 162 oestrogen and 256 support network 130 Nocturnal enuresis 342, 346–7, 430 pharmacological management transition 131–2 see also antenatal classes diet 347 260–4 Partogram 68, 69 (fig.), 70 management 347 HRT and 254, 260–2 Peak bone mass (PBM) 256 Nocturnal polyuria 434 Peanuts, pregnancy 122 Nocturnal urine volume, definition see also hormone replacement Pediculosis pubis 273 therapy (HRT) Pelvic denervation 397 434 Pelvic diaphragm see levator ani Non-steroidal anti-inflammatory drugs non-HRT drug therapy 263–4 muscles pregnancy-associated 154–5 Pelvic floor 5–10, 9 (fig.) (NSAIDs), endometriosis 282 prevention 257–8 dyssynergia 389 Nutrients, pregnancy 120–1 risk factors 257 (box) exercises see pelvic floor muscle treatment 259–60 O vitamin D 258 exercises Ovarian cystectomy 313 labour and 55, 65–6 Obesity, pregnancy 39 Ovaries 14 ligaments 5 Oblique muscles 11 cancer 280–1 muscles see pelvic floor muscles Obstetric care, antenatal 96–7 cysts 280 Obstetric history, bowel dysfunction (PFM) removal 313 neuropathy due to prolonged 404 follicles 14 Obstetric physiotherapist, role premature failure 293–4 labour 59 Ovum (egg) 14 Pelvic floor muscle exercises 108, xix–xx Oxygen, increased demand Obturator internus 7 labour 64 108 (fig.) Occipitoposterior position (OP) 75–6, pregnancy 37 antenatal 108 Oxytocic injection 72–3 home 219 198–9 Oxytocin importance 335, 347 Occupational therapists, faecal labour interventions 72–3, 79 lower urinary tract dysfunction 445 labour role 56, 57 misconceptions 349 incontinence 402 rise during labour 56 perineal dysfunction/pain 222 Oedema postnatal 212, 213 P gravitational 88 physiotherapist’s role 211 postnatal 207, 230 Pad test 354–5, 436 practice sessions 371 pregnancy 43 Pain progression 371–2 measurement 98 control see pain relief stress incontinence 241 Oestrogens 14, 30 definition 59–60 teaching 368–72 labour see labour bone metabolism 256 Pain relief contractions 370 breasts 38 labour 63, 129, 184–96 instructions 369–70 cognitive performance 253 language 369 deficiency 254 acupuncture 189 starting position 369 effects in pregnancy 4, 33 Entonox 190–1 visualisation 369 fluid retention 37 in labour 57 replacement 261 cardiovascular disease and 255

484 INDEX Pelvic floor muscles (PFM) 5–10, 11 Penthrane (methoxyflurane) 190 stress reduction 111–12 assessment PERFECT scheme 357 relaxation methods 169 biofeedback 357–60, 372–5 Periform 376 TENS 188, 189 computerised manometric Perimenopause 250 urinary function assessment 349–52 359–60 Phyto-oestrogens, osteoporosis electromyography (EMG) 358–9 see also climacteric confirmation of contraction 357, 370 Perineal body 10 treatment 264 damage 207 Perineal membrane 6, 9–10 Pilates, maternal exercising 119 electrical stimulation 375–6 Perineal pain syndrome 433 Pinard stethoscope 99 examination 355–7 Perineometer 358 Piriformis 7 chaperone 356 Perineum 10 Placenta 29–30 consent 356 guidelines 355 assessment 355–7, 435 delivery 55, 59, 72 procedure 356–7 chaperone 356 passage of substances across 30, 191 exercise see pelvic floor muscle consent 356 retained 79, 199 exercises guidelines 355 Placenta accreta 79 function 6 procedure 356–7 following caesarean section 83–4 definition 436 Placental abruption 44 gynaecological surgery 325, 326–7 dysfunction/pain labour complications 77 micturition 338–9 ice therapy 222–3 Placenta praevia 44, 47–8, 198 neurological control 341 physiotherapist’s role 222 diagnosis 48 strength grading 357 postnatal 213, 221–4, 240 following caesarean section 83–4 stress incontinence 225, 241 treatment 222–4 Pollakisuria 342–3, 429 voluntary contraction (VPFMC) Polycystic ovarian syndrome 103, 292 344–5, 346 labour, effect on 65–6 Polyhydramnios 30, 48 weakness 346 massage 78, 182–4 Polymenorrhoea 288 see also specific muscles postnatal 85, 207 Polyp 278 superficial muscles 7 Polyuria, measurement 434 Pelvic girdle support during defaecation 391 Postcoital dysuria 347 pain, pregnancy 142–9 tears Postmenopausal women 250 assessment 147–9 bleeding 249 examination 148–9 anal incontinence 400 problems 254–5 management 146–7 classification 78 Postnatal care 208–21 pregnancy effects 42 labour complications 78–9 breastfeeding 208–10 support following 213 classes see postnatal classes Pelvic inflammatory disease (PID) Peritron 358 (fig.) following caesarean section 237–9 275–6 Pethidine 191–2 physiotherapy 210–11 Pfannenstiel incision 82, 310 postnatal check 209–10 cause 274 Phenylephrine gel 413 posture 214–15 Pelvic organ prolapse Physiotherapy 94 routine 208 bowel function assessment 402–10 Postnatal classes 214–21 definition 436 breastfeeding assistance 208–9 baby massage 220–1 lower urinary tract symptoms 431 gynaecological surgery community exercise classes 220 Pelvic pain postoperative 326–30 educational principles 215 childbirth during/after 5 preoperative 322–6 home exercises 219–20 definition 432 labour education 167 relaxation 215 pregnancy 142–9 labour preparation 166 return to sport 220 syndrome 433 postnatal 210–13 setting up class 214 Pelvic radiotherapy 314 assessment 211–12 teaching ergonomics 216–19 Pelvic splanchnic nerves 20, 22 classes 214–21 teaching points 214–15 Pelvic tilt 42, 108, 227 exercise 212–13 Postnatal depression (PND) 132, 233, ‘Pelvic trampoline’ 5, 8 exercise advice 214–21 Pelvis 1–5, 2 (fig.) individual vs. group 212 235 circulation 17 posture advice 214–21 baby massage 221 contracted 77 role 210–11 long term 244 diameters 3 (table) venue 212 Postnatal period 205–48 different types 3 (fig.) postnatal check 210 after-effects of instrumental female vs. male 1 postnatal depression 235 in labour 3 pregnancy intervention 236–40 muscles 5–10 back pain 143 care during see postnatal care nerve supply 17 breastfeeding 134–5 circulatory dysfunction/pain see also entries beginning pelvic exercise advice 117–18 interaction with father 133 230–1

Index 485 depression see postnatal Prebiotics 410 reproductive system 33–6 depression (PND) Preconceptual care 102–4 respiratory system 37–8 Pre-eclamptic toxaemia 48–9 skin 38–9 genitourinary dysfunction/pain Pregnancy 27–53 urinary system 41 224–6 weight gain 40 (fig.) back care 106, 106 (fig.), 107 (fig.) physiological anaemia of 36 immediate problems 221–4 comorbidity 44 sexuality 300 long-term complications 240–4 complications 43–52 smoking 123–4 defaecation difficulties 396 unstable/transverse lie 49–50 dyspareunia 240–1 diaphragm 38 see also antenatal care perineal pain/discomfort 240 diet during see diet Pregnancy-associated osteoporosis vaginal pain/discomfort 240 discomfort relief 141–64, 157–9 154–5 multiple births 239–40 Pregnancy hypotensive syndrome musculoskeletal dysfunction/pain back and pelvic pain 142–50 37 chondromalacia patellae 159 Pregnancy test 41 226–30 circulatory disorders 157–9 Prelabour 36, 53–4 psychological symptoms 233–6 coccydynia 153–4 Premature delivery 31, 200 puerperium see puerperium fatigue 161 maternal exercising and 115–16 sexual problems 235–6 fibroids 160–1 Premature ovarian failure (POF) Postpartum headache, epidural heartburn 161–2 293–4 incontinence (urinary) 162 Premenopausal women 250 anaesthesia 195 insomnia 161 sexuality 301 Posture morning sickness 162 Premenstrual tension (PMT) 290 nerve compression syndromes legal cases 290 bad, musculoskeletal symptoms Pressure flow studies 442–4 217–19 155–7 Private antenatal care 97 nightmares 161 Procidentia 286 caesarean section 238 osteoporosis 154–5 Proctalgia fugax 389 defaecation 387–8, 388 (fig.), 414 postural backache 154 Progesterone 14 gynaecological surgery 325, 327 pruritus 161 blood vessels, effect on 36 infant feeding 217 (fig.) restless leg syndrome 159–60 effects in pregnancy 32–3 kneeling 217 sacroiliac joint dysfunction Progestogens, foetal development labour 177–80 30 150–2 Prolactin 85 ‘all-fours’ 67 sciatica 152 Prolapse see genital prolapse birth cushion 178 symphysis pubis dysfunction Prolapsed cord 56, 76 birth partner’s role 177–8 Prostaglandins first stage 179 (fig.) 153 labour interventions 79 kneel fall 180 (fig.) urinary disorders 162 production in labour 57 leaning forward 177, 178 (fig.) uterine ligament pain 160 Pruritus second stage 71, 180 (fig.) see also individual problems pregnancy 161 sitting position 67 early care 104 vulval 272 squatting position 67, 178 ectopic 15, 45 Psychiatric disorders, defaecation supine position 68, 178 (fig.) estimated date of delivery (EDD) difficulties 397 upright position 66 Psychological aspects, gynaecological postnatal 216 (fig.) 30 surgery 321–2 bathing baby 219 exercise during see exercise Psychological effects, childbirth 167 feeding 217–18, 217 (fig.) father’s role 132–3 Psychological problems, constipation lying 214–15, 216–17 foetal development 29–31 399 nappy changing 218–19, 218 Psychological symptoms, postnatal see also foetus 233–6 (fig.) insomnia 161 Psychosexual problems 294–8 sitting 214, 216 mask of (chloasma) 38 aetiology 294–5 standing 214, 216 medications during 124–5 see also sexual dysfunction teaching points 214–15 multiple 47, 125 Pubocervical fascia 18 pregnancy 42, 148–9 Pubococcygeus 5–6 back pain prevention 143–6 preterm delivery 125 during labour 55 myths 300 type ll muscle fibres 10 (table) lifting 146 physical/physiological changes lying 143–4 rolling 144 31–43, 35 (fig.) sitting 144–5 breasts 38 standing and walking cardiovascular system 36–7 endocrine system 32–3 145–6 gastrointestinal system 39 see also back pain musculoskeletal system 41 Postvoid residual (PVR) 343 nervous system 40 Potter’s syndrome 47 Pouch of Douglas 22

486 INDEX Puborectalis muscles 6 antenatal 109–10, 112 (fig.), 219 self-help 151 (fig.), 152 (fig.) defaecation 388 benefits 168 side lying 152 during labour 55 in labour 129 TENS 152 paradoxical contraction 389 postnatal 215 Sacroiliac ligaments, ventral (anterior), techniques 167–9 posterior 2 (fig.), 3 Pubovaginalis 6 Sacrum 3–4 Pubovisceralis 5–6 assessment 169 rotation under loading 4, 4 (fig.) Pudendal nerve 10 dissociation and unblocking Safe Motherhood Initiative 95 Salmonella, in pregnancy 121 damage during labour 65 168–9 Salpingectomy 313 elderly 399 imagery 170 Salpingitis 275 Pudendal nerve terminal motor Mitchell method 168 Salpingostomy 316 teaching 169–70 Scabies 273 latency (PNTML) 409 tense–relax technique 168 Sciatica 152 Puerperal infection 88 touch relaxation 169 Sclerosis, sacroiliac joints 150 Puerperal psychosis 234–5 Relaxin 33, 38, 42 Scrotal pain 432, 433 Puerperium 84–8 Renal disorders, preconceptual care Seat belts, correct position 106, 107 102 (fig.) ‘after-pains’ 84, 229–30 Reproductive tract 13–18, 14 (fig.) Selective oestrogen receptor complications 87–8 circulation and nerve supply 17 modulators (SERMS), defaecation difficulties 396 fallopian tubes 15 osteoporosis treatment 263 lactation 85–6 ovaries see ovaries Sensory blockade, epidural loss of baby 199–200, 201 pregnancy effects 33–6 anaesthesia 194 management 86–7 suspensory ligaments 17–18, 18 Sexual abuse perineum 85 bowel dysfunction 404 (fig.) defaecation difficulties 391 dysfunction/pain 221–4 uterus (womb) see uterus Sexual dysfunction 295 physical condition 206–7 vagina see vagina male 253–4 psychological state 207 Respiratory system postnatal 235–6 psychosis 234–5 gynaecological surgery 323–4 see also psychosexual problems sexuality 300–1 labour, effect on 64, 170–1 Sexual intercourse sexual problems 300 maternal exercising 115 labour induction 57 stillbirth 200–1 pregnancy effects 37–8 lower urinary tract symptoms uterus 84–5 see also breathing vagina 85 Rest 431 Pulmonary embolism, postnatal 87–8, after labour 86–7 urinary incontinence and 347–8 antenatal 219 Sexuality 300–3 231 Restless leg syndrome, pregnancy ageing 301–2 Pulsed electromagnetic energy cancer 303 159–60 climacteric 253–4, 301–2 (PEME), perineal Retraction 15 pregnancy 300 dysfunction/pain 224 Rhabdosphincter (striated urogenital premenopause 301 puerperium 300–1 Q sphincter muscle) 20 Sexually transmitted disease (STD) Rhesus negative blood group, Quality of life questionnaire, 273, 274 incontinence assessment 360 umbilical cord clamping 72 pelvic inflammatory disease 275 Rheumatoid arthritis, pregnancy 44 testing in antenatal care 99–100 R Royal College of Midwives (RMC) xvii Sexual self rating (SSR) scale, Royal College of Obstetricians and Radiotherapy, pelvis 314 premenopause 301 Raloxifene, osteoporosis treatment 263 Gynaecologists (RCOG) Sickle cell disease (SCD), pregnancy Randell, Minnie xvii intimate examinations guidelines Rectal sensitivity training 418–19 49 Rectoanal inhibitory reflex (RAIR) 386 355 Sitting water birth guidelines 190 testing 408 postnatal care 216 Rectocoele 285 (fig.), 287, 396–7 S pregnancy 144–5 puerperium 214 surgical treatment 315–6 Sacral colpopexy 316 Skin Rectovaginal fistula 225 Sacroiliac joint 1 menopause 252–3 Rectovaginal septum, tear 396 Sacroiliac joint dysfunction 5, 146–7, pregnancy 38–9 Rectum 22, 23 (fig.) Small for gestational age (SFGA) 31 150–2 Smoking defaecation 387 treatment 150–2 Reflex latencies, urinary tract 462–3 Relaxation 130, 167–70 Cyriax 151 leg pull 151

Index 487 cessation 124 Surgery pregnancy 159 menopause and 249 anal fissure 396 puerperium 87–8, 230 pregnancy 123–4 anal incontinence 400 Thrush 272 Soiling, passive 389 endometriosis 282–3 Tibial nerve compression, pregnancy Sonic-aid monitor 99 see also gynaecological surgery Special care baby unit (SCBU) 200 157 Sphincterotomy, anal fissure 396 Suspensory ligaments 17–18, 18 (fig.) Tibolone, osteoporosis treatment Spinal anaesthesia, total 195 Swimming 118–19, 220 Stages of labour 54–5 Symphysis pubis 1 263 Standing Toxoplasmosis, pregnancy 121–2 postnatal posture 214, 216 diastasis 242 Transcutaneous electrical nerve pregnancy 145–6 dysfunction (SPD) 106–8, 153 Staphylococcus 272 pain 5, 142, 229 stimulation see TENS Statins, osteoporosis treatment 264 Syntocinon 196 Transformation zone, large loop Stillbirth 200–1 Stimulants, bowel dysfunction 412 T excision 313 St Mark’s Hospital, four stage Translabial real-time ultrasound Tamoxifen, osteoporosis treatment 263 ‘holding on’ programme 411 Temperature (body) 410 Stoma cells 14 Transperineal real-time ultrasound Stool(s) foetal malformations and 115 labour effects 65 410 blood in 394 TENS 185–9 Transvaginal sacrospinous fixation Bristol stool chart 385 (fig.) brief intense 186–7 liquid 401 burst train 186 316 Straining considerations 188 Transverse abdominis contractions, anal incontinence 401 electrode placement 187 prolonged, defaecation difficulties low back pain in pregnancy 149 position for 108 (fig.) meralgia paraesthetica 157 ‘Transverse arrest’ 76 397 midwives 189 Transverse cervical ligaments 18 Strength duration curves 410 modes of stimulation 186–7 Transverse lie 49–50 Stress obstetric units 189 Transversus abdominis muscle sacral electrodes 188 antenatal period 109–10 sacroiliac joint dysfunction 152 11 constipation 399 safety 187–8 Trauma, anal incontinence 400 labour 64 spinal electrodes 188 Triangular ligament see perineal physiological effects 110–11 trials 185–6 reducing techniques 103 Tension-free vaginal tape (TVT) membrane scale 111 (table) Trichlorethylene (Trilene) 190 Stress incontinence 225, 317–18, 430, 317–18, 319 Trichomonas vaginalis 274 Term Breech Trial 75 Trigone 19 469 Testosterone Trilene (trichlorethylene) 190 definition 435 Trophoblast 29 gynaecological surgery 317–20 female implants 261 Tumour(s) see cancer postnatal complication 241 male decline 253 Tuohy needle 193 surgical procedures 317–20 Tetracycline, pregnancy 124 TVT see tension-free vaginal tape treatment 367 Thalassaemia, pregnancy 49 Twins and Multiple Birth Association urodynamic (USI) 345–6 Thalidomide, pregnancy 124 Stretch marks (striae) 39 ‘The knack’ 367, 371 (TAMBA) 240 Stretch receptors Thermoregulation, maternal anorectal region 23 U bladder wall 339 exercising 114 Striated urogenital sphincter muscle Thighs, discomfort during labour 61 UK Central Council, TENS ‘Third day blues’ 234 recommendations 189 20 Thoracic arteries, internal 13 Stroke, HRT and 255 Thoracic region Ultrasound Stroke volume, pregnancy effect 37 antenatal screening 101 Subfertility 103–4, 293 lordosis 142 bladder 360–1 Subtotal hysterectomy 311 pain 142, 228 foetal heart monitor 70 Sudden infant death syndrome (SIDS) spine pain 154 perineal dysfunction/pain 223 Thromboembolism 159 real-time 410 201 Thrombosis smoking risk 124 deep vein thrombosis (DVT) Umbilical cord Suicide 94 clamping 72 Supervisor of Midwives 95 postnatal 230–1 controlled traction 73 Supine hypotension 114 postoperative 328 knotted 76 prolapse 56, 76 Umbilical ligament, median (urachus) 20 Undeveloped countries, maternal deaths 93–4

488 INDEX UNICEF UK Baby Friendly Initiative, electrophysiological tests 363–4 Urinary leaking 430 ten steps of successful form 350–1 (fig.) Urinary output, pregnancy 41 breastfeeding 134 imaging 364 Urinary retention 349 physiotherapy 349–61 Unstable lie 49–50 questionnaires 360 acute 444 Ureter 19 urethral pressure profilometry chronic 445 Urethra 17, 20–2 epidural anaesthesia 194 362 postnatal 225–6 blood supply 21 urinalysis 352 Urinary tract 18–22 distal electric conductance 363 urinary flow 456–7, 457 (fig.) bladder see bladder dyssynergia 349 urodynamic/radiological/EMG infection 361 function 470 kidney 18–19 361–4 lower see lower urinary tract filling cystometry 441–2 uroflowmetry 362–3 neurophysiological evaluation micturition 443, 444 VAS 360 storage phase 468 definition 435 460–5 pain 432 detrusor overactivity 343–5, 346 electromyograph (EMG) 460–2 Urethral pain syndrome 432 idiopathic 344 evoke responses 464–5 Urethral pressure profile (UPP) 362, neurogenic 344 nerve conduction studies 462–3, 452–4 terminology 344–5 definitions 453–4 VPFMC 344–5 464–3 female, ICS recommended exercises to prevent 108 reflex latencies 464 extra-urethral 343 sensory testing 465 nomenclature 454 (fig.) factors leading to 335 pregnancy effects 41 storage phase 452–3 frequency 342, 429 urether 19 technique 453 functional 348 urethra see urethra voiding (VUPP) 362, 459 giggle incontinence 347 Urinary urgency 398, 429, 433 Urethral sphincter 20–1, 21 (fig.) history 351–2 postnatal 226 Urethral syndrome 252 caution 352 Urine Urethrocoele 285, 285 (fig.) infection 361 analysis during pregnancy 98 treatment 314 mixed 345 average flow rate (AUFR) 338 Urethrovaginal sphincter 21 treatment 368 increased output after labour 85 Urethrovesical angle 20, 338 nocturnal enuresis 342, 346–7 loss, quantification 454–6 Urge incontinence 345, 377, 430 pad test 354–5 maximul urine flow rate (MUFR) paper towel test 355 see also urinary dysfunction and patients at risk 335 338 urinary incontinence, detrusor perineal/vaginal assessment 355–6 pressure flow studies 442–3 overactivity persistant 379 residual 459–60 Urinalysis 352 pregnancy 41, 162 storage 337, 339 Urinary dysfunction 342–82 prevalence 334 storage evaluation 450–6 causes 365 (table) prevention 335 incontinence see urinary recent developments 335 cystometry 450–2 sexual activity-associated 347–8 quantification of urine loss 454–6 incontinence stress see stress incontinence urethral pressure measurement lower urinary tract see lower treatment 364–79 additional techniques 367–8 452–4 urinary tract dysfunction attendance 372 voiding see micturition menopause 252 bladder retraining 377 Urodynamic conditions 444–5 preconceptual care 103 continence-promoting advice see also lower urinary tract pregnancy 162 understanding 364 368 dysfunction urgency 226, 343–5, 429–30 devices 379 Urodynamic stress incontinence (USI) Urinary function 333–42 electrical stimulation 375–6 continence 333 home 367, 376 345–6 persistent problems 379 Urodynamic studies 428, 436–44 problems 334 principles 367 factors in normal 341–2 sociological problems 366 ambulatory 437 micturition see micturition types 343–8 conventional 436–7 understanding 364 see also lower urinary tract filling cystometry 361, 437–42 Urinary incontinence 20, 224, 225, pressure flow studies 362, 442–4 dysfunction symbols 471–2 343–82, 429, 430, 468–9 Urinary infections 17, 20, 361 units of measurement 470–1 assessment Uroflowmetry 362–3 Urogenital diaphragm see perineal bladder ultrasound 360–1 cystometry 361–2 membrane distal urethral electric Uterine contractions conductance 363 Braxton Hicks 36

Index 489 breathing 172–7 during labour 58–9 postoperative complications 328 first stage of labour 54 guidelines 355 symptoms 430–1 hypertonic 198 labour 68 see also micturition hypotonic 198 procedure 356–7 Vomiting in pregnancy 39 labour sign 56 stress incontinence 241 HCG role 30 oxytocin effect 56, 57, 84, 197 transition stage 174–5 hyperemesis gravidarum 39 Uterine ligament, pain, pregnancy vaginal cones 374 Vulva Vaginal discharge 273–4 cancer 277–8 160 family planning method 27, 29 disorders 272 Uterine muscles 17 menstruation cycle, changes infections 271–3 Uterine prolapse 286–7, 286 (fig.) pain 432, 433 during 27, 29 surgery 313 surgical repair 316 Vaginal haematoma 221 varicose veins 157–8 Uterine tissue, in puerperium 84–5 Vulval pain syndrome 433 Uterosacral ligaments 5, 18 labour complications 78 Vulvar vestibulitis 299 Uterus 15–16 Vaginal hysterectomy see Vulvectomy 313 Vulvitis 271–2 anteflexed 283 hysterectomy Vulvodynia 298–9 anteverted 283 Vaginal pain/discomfort 240 Vulvovaginitis 271 benign tumour 278–9 collagenous tissue 35 definitions 432, 433 W congenital malformations 15–16 Vaginal pain syndrome 433 didelphys 15–16 Vaginal vault prolapse – surgical Walking fibroids 45–6 postnatal exercise 219 growth during pregnancy 33–6, 34 repair 316 pregnancy 145–6 Vaginal wall, repair 314 (fig.) Vaginismus 295–6 Water births 95, 190 infections 275 safety 190 malignant tumour 280 primary 295 muscle fibres 16 (fig.), 35–6 secondary 296 Water retention, pregnancy 40, 43 puerperium 84–5 Vaginitis 273 ‘Waters,’ breaking of 55–6 removal see hysterectomy Valsalva manoeuvre 64 Weight gain in pregnancy 39, 40 (fig.), retroflexed 284 Varicose veins retroverted 284 postnatal 230 119–26 see also entries beginning uterine pregnancy 37, 157 labour duration, effect on 66 vulval 157–8 measurement during 98 V Vascular plexus 21 normal 119 Vena cava 17 Wertheim’s hysterectomy 311 Vacuum extraction (ventouse Venereal Disease Research Laboratory Womb see uterus delivery) 199 Workplace, defaecation difficulties (VDRL) 100 labour interventions 81 Venous thromboembolism (VTE), 393 unassisted vaginal birth vs. 211–12 World Health Organization (WHO), Vagina 16–17 HRT 260 atrophy 250, 251–2 Ventouse delivery see vacuum breastfeeding cysts 278 recommendations 133–4 disorders 273–4 extraction (ventouse delivery) Wound healing, caesarean section menopause 250 Very low birth weight infants (VLBW) 238 Wound infection, postoperation soreness 251 31 complications 328 prolapse 436 Vesicovaginal fistula 88, 94 Wrigley’s forceps 81 in puerperium 85 Violence, in pregnancy 98 tearing during labour 65 Viral infections 273 Y see also entries beginning vaginal Visual analogue scale (VAS), Vaginal assessment 355–7, 391, 435–6 Yoga, maternal exercising 119 chaperone 356 incontinence assessment 360 consent 356 Visualisation and imagery, neuromuscular control 112 Vitamin D, osteoporosis 258 Vocalisation, in labour 174–5, 176 Voiding, prompted, timed 377 Voiding difficulties 348 Voiding dysfunction 444