Care study of a woman with a care issue which related to the module content. You are expected to analyse the evidence base, which informs choices and practice and evaluates client care, making recommendations for improvement.
In this essay we shall consider the case of Mrs.J. a 32 yr. old primigravid mother who has had a totally uneventful pregnancy. She is a large caucasian lady with a BMI of about 30. Her blood pressure and biochemistry were normal throughout her pregnancy. She is a non-smoker.Progressive Urge Incontinence Essay
Her major problem was that she has suffered from progressive urge incontinence as her pregnancy progressed, which developed into stress incontinence by about the 33rd week. She subsequently had a normal vaginal delivery of an 8lb 2oz baby boy, which proved to be unexpectedly rapid so there was no time to do an episiotomy. She suffered a few small 1st degree tears. Post natally her stress incontinence got very much worse and now ( six months post delivery) it is a major problem for her.
Stress incontinence is a common post partum condition which can occur over a full range of severity from subclinical to catastrophic. It is usually described as “the involuntary passage of urine associated with a sudden, or impulse, rise in the intra-abdominal pressure” (Arya et al.2001)
It occurs in about 11-13% of post partum women (Cammu et al 1997)). Other authorities such as Norton (1996) put the prevalence of the condition in the whole adult population at about 40 per 1000. The Continence Foundation (2000) estimates that there are about 3 million women who are over the age of 40 who suffer from varying degrees of the condition.
Aetiology of the condition
Pelvic floor trauma during childbirth has been recognised for a long time as being a major contributory component (if not an actual cause) of stress incontinence. Many studies have been done to try to ascertain the most effective modalities of treatment and others have looked at the factors associated with pregnancy and childbirth which are germinal to the condition. In this essay we shall consider the work that has been done in specific relation to the case of Mrs.J.
The first factor to consider in respect of Mrs.J. is the fact that she is pregnant. This may seem to be blindingly obvious at first sight, but it has only recently begun to be recognised that quite apart from post natal and delivery-related factors, there are a number of antenatal factors that relate directly to stress incontinence. Rortveit (et al 2003) produced a carefully executed study which pointed to the fact that, even if no other factors were apparent, pregnancy, by itself, was an independent variable for the development of stress incontinence. This study showed an increased incidence of 1.7 times the incidence for nulliparous women when corrected for all other variables. This study supersedes (in both time and quality) previous studies by Nielsen (1988) and Olsen (1997) which looked at the same issue but could not produce a statistically significant answer.
If we consider the actual mode of delivery we see that Mrs.J. had a fairly precipitate delivery of a large baby without the benefit of an episiotomy. We might observe that she was fortunate not to sustain a major perineal tear. There have been many studies (of variable quality) which have looked at the issue of the relationship between the mode of delivery and the eventual incidence of stress incontinence.
A recent study by Burgio (2003) found that there were a number of independent variable factors that were predictors of an eventual increased incidence of stress incontinence. These included “smoking during pregnancy, length of time spent breast feeding, a vaginal delivery, the use of forceps to assist delivery , the frequency of urination prior to delivery and BMI”. In specific relation to Mrs.J. we can see that a number of these identified factors are present. She had a vaginal delivery, suffered from urge incontinence prior to delivery and has a high BMI.
Other factors such as a large birth weight baby, (Groutz et al.1999) precipitate delivery (Perry et al 2000) and lack of episiotomy (Reilly et al. 2002) have also been identified by other investigators as being potent causative agents in the development of stress incontinence.Progressive Urge Incontinence Essay
The study by Perry (et al 2000) considered the intra-partum factors that influenced the eventual incidence of stress incontinence and concluded that factors such as a precipitate delivery (together with malpresentations and malrotations) increased the incidence of perineal floor damage which was a prime factor in the aetiology of stress incontinence.
This factor was examined further by Reilly (et al. 2002) who came to the conclusion that episiotomies exert a protective effect on the perineum (by minimising damage in labour and by allowing the various structures to be safely surgically repaired), and the presence of an episiotomy statistically reduced the eventual incidence of stress incontinence.
The issue of the relationship between BMI and stress incontinence was settled by Seim (et al 1996) whose study showed a statistically significant increase in the incidence of stress incontinence with increasing BMI