Version 1, December 2023

Forewords

Every health professional working with women perinatally has an opportunity to support their pelvic health.

Establishing Perinatal Pelvic Health Services (PPHS) is the means to make this happen. PPHS will provide focus to the prevention, identification and timely treatment of a range of issues antenatally, and for at least 12 months after birth.

This focus is much needed. Studies over a number of years have shown that a significant proportion of women experience urinary incontinence, faecal incontinence and pelvic organ prolapse around or following birth, with potentially devastating consequences on quality of life and wellbeing. And yet these problems too often go undetected due to embarrassment, or a mistaken belief that these issues are ‘normal’, or that no-one can help. Specialist provision in this area has also varied significantly across England.  

The establishment of PPHS across England is therefore not only a milestone in NHS England’s work to improve postnatal care. It is an opportunity for every Integrated Care Board to address regional inequalities and improve the health of women now, and in later life.

This implementation guidance was made possible thanks to the expertise and commitment of the national Perinatal Pelvic Health Implementation Group. It is filled with learning from over 2 years of pilot implementation, and across 28 of the 42 Local Maternity and Neonatal Systems in England.

We hope you find it useful, so that together we can make the most of this opportunity.

Kate Brintworth
Chief Midwifery Officer, NHS England

Professor Donald Peebles
National Specialty Advisor for Obstetrics, NHS England

This guidance represents an important milestone in the development of vital Perinatal Pelvic Health Services (PPHS), created to improve access to early intervention and support for women and people experiencing symptoms of pelvic floor dysfunction.

We know that this can have a debilitating and distressing impact on women, yet research in 2022 by the Royal College of Obstetricians and Gynaecologists (RCOG) showed there remain significant barriers to women and people seeking help, including a lack of knowledge about pelvic floor health and embarrassment discussing the symptoms of pelvic floor dysfunction.

Obstetricians, gynaecologists and midwives are well placed to support women experiencing pelvic floor dysfunction, which is why our two Royal Colleges welcome this guidance. We are optimistic that, with the necessary investment, PPHS will play a central role in providing timely access to support, allowing better identification and early intervention to prevent poorer outcomes for women with symptoms of pelvic floor dysfunction. PPHS have the potential to maximise the benefits of greater multidisciplinary team-working, and increasing access to specialist care for pelvic floor dysfunction around birth.

We are delighted that this service specification sets out how PPHS will work with maternity units to implement the joint RCOG and RCM Obstetric Anal Sphincter Injury (OASI) Care Bundle. Too many women currently suffer these injuries during childbirth, which can mean long-term complications including difficulty controlling the bladder and bowel, chronic pain and painful intercourse. The care bundle is a set of evidence-based interventions likely to improve OASI outcomes when implemented together.

The RCOG and the RCM look forward to supporting the implementation of this important guidance, working with our membership and our NHS partners to help ensure all women have access to high-quality pelvic floor health information, education and care.

Dr Ranee Thakar
President, Royal College of Obstetricians and Gynaecologists

Gill Walton
CEO, Royal College of Midwives

Pelvic Obstetric and Gynaecological Physiotherapy (POGP) wholeheartedly support and drive forward this guidance. The establishment of Perinatal Pelvic Health Services nationwide is a huge step forward to providing women with the knowledge and support that they require through the antenatal and postnatal period, and an open door beyond the immediate postnatal period to receive the specialist physiotherapy that they need when they develop symptoms that impact on their quality of life.

The roll out of these services will level up perinatal care across the UK. Further, it will change the dialogue for women from confusion about when and where to get help and what to tolerate as ‘normal’ to an expectation of specialist care to optimise their perinatal experience and minimise their future pelvic floor problems.

POGP aims to provide evidence informed care and advocacy for its members and the public and this guidance brings into focus the key role that pelvic health physiotherapy has in wellbeing for women who experience childbirth. The PPHS sites that have been established to date have demonstrated that change in NHS provision requires support at all levels, and creating opportunities for specialist clinicians to develop healthcare strategies that work for service users results in a tailored and effective package of care.

This guidance will reduce the anxiety experienced by women who can’t find the help that they require and will give them voice to ask without fear. It will be a step forward in future proofing the workforce for specialist clinicians in pelvic health from undergraduate level to leadership roles in the NHS.

Dr Kate Lough
Chair, Pelvic Obstetric and Gynaecological Physiotherapy (POGP)

It has been a privilege to be a part of the Perinatal Pelvic Health Services Implementation Group, which coproduced the Service Specification, and this Implementation Guidance.

We are so pleased to see that pelvic floor dysfunction will begin to receive the attention and investment that it deserves. We hope the establishment of PPHS across England will change the culture for clinicians and members of the public alike. Pelvic floor problems should no longer be seen as “normal”, or something that service users must simply accept as an inevitable consequence of pregnancy and birth, nor viewed as a postnatal problem that can only be treated with surgical intervention once family planning is complete. We are reassured to see that prevention and early detection of problems are at the forefront of this new investment, with recognition that pelvic health is a life course issue.

We also welcome the focus on the connection between physical health and mental wellbeing, in cases of pelvic floor dysfunction. We have both experienced the significant negative impact that pelvic health problems routinely have on mental health, antenatally and postnatally.

We believe that implementing effective PPHS is reliant on multi-disciplinary team working, and on truly co-producing services with experts by experience.

We hope that with PPHS established across England, no other woman or birthing person faces the embarrassment, pain, fear and hopelessness that we suffered before we were finally able to access the care and treatment that made all the difference.

If only PPHS were delivering this standard of care when we needed it.

Mahdieh Irvine-Naderali, Emma Crookes
National service user voice representatives, lived experience of perinatal pelvic floor dysfunction

Produced by NHS South Central and West (SCW) and NHS England.

1. Implementing a Perinatal Pelvic Health Service

1.1.   Introduction

The national service specification sets out the standards of care that Perinatal Pelvic Health Services (PPHS) should provide and how each service should function. This document provides guidance on how to establish a system-wide, coproduced service. For each section in the service specification, it sets out:

• relevant national guidance, standards and evidence;
• the support and resources available for implementation; and
• examples of good practice from pilot services.

1.2.   What is the national ask on systems?

The Three Year Delivery Plan for Maternity and Neonatal Services includes the ask that:

This means having a commissioning arrangement agreed with the local integrated care board (ICB) that includes:

• Where a fully functioning PPHS is not in place, an implementation plan (see 4. Developing a plan), including any fixed-term staffing and associated funding arrangements for the implementation project team (see 1.3. Bringing together the project team).
• For all systems, a clinical staffing plan including banding and whole-time equivalency (WTE) of funded establishment, and a linked spending plan for business-as-usual operation (See 4. Developing a plan).
• Clear reference to the standards set out in the national Service Specification and the KPIs that will be reviewed locally to monitor performance (see Key Performance Indicators).
• Governance arrangements for operational and professional oversight of the service, including the review of KPIs, issues, and risks (see 4. Service governance and leadership)

This will ensure that the additional national investment into PPHS is assured in future years, when from 2024/25 this funding rolls into system baselines for sustainable operation.

1.3.   Bringing together the project team

A project team will need to be brought together to manage and oversee the planning and establishment of the PPHS.

As set out in LMNS funding letters shared in March 2023, every system without a PPHS should begin immediately the recruitment of a project management officer (PMO) with dedicated capacity (at least 0.6 WTE) to drive forward the planning and implementation of the service. Across the 28 pilot Systems nationally, there has been a very strong correlation between dedicated project management capacity and the successful implementation of PPHS. The PMO should be appointed on a fixed-term basis until the service is established, at which point funding can be re-allocated to further increasing substantive clinical establishment.  

The project team should also include at a minimum:

• Senior responsible officer (SRO): To be accountable for the delivery of the service and benefits. This may be the LMNS SRO.
• Physiotherapy lead: To provide clinical and strategic leadership and direction from a physiotherapy perspective. It is recommended that this is a Pelvic Health Physiotherapist at band 8a or above. See 3. Staffing for further details.
• Midwifery lead(s): To provide clinical and strategic leadership and direction from a midwifery perspective. Larger systems with multiple providers should consider identifying a lead for each provider, to ensure consistent and effective change in local practice and care.
• Obstetrics and gynaecology lead(s): To provide clinical and strategic leadership and direction from the perspective of obstetrics and gynaecology.
• Primary care lead: To provide expert input and ensure co-ordination with local primary care services.
• Service user voice representative: All PPHS should have at least one service user representative on the project team to provide input from the perspective of service users. Ideally, this representative will have lived experience of perinatal pelvic health problems. PPHS should fund this role in line with local ICB remuneration policies.
• Other relevant professionals: PPHS should also consider involving other relevant professionals on their project team, such as representatives from colorectal, urogynaecology, health visiting, and mental health services.

Each of these positions could, helpfully, be funded on a low WTE to ensure buy-in and effective input on a fixed-term basis, such as until a service model is agreed or the service is established. At this point funding should be re-allocated to further increasing business-as-usual clinical establishment for the PPHS.

1.4.   Developing a plan

The project team will need to coproduce a plan – agreed and signed off by the LMNS – that describes the local service and how it will be established. Plans should align with the responsibilities and requirements set out in the service specification but be adapted to meet the needs, expertise, and opportunities of the local area.

Local plans should be developed in collaboration with relevant services and coproduced with service users (see 1.5 on service user engagement, and 2.2 on service interdependencies).

The plans should be taken with the national service specification through relevant local integrated care system (ICS) governance structures for sign-off and to ensure senior buy-in.

PPHS are recommended to complete the following documentation as part of the planning process:

Service baseline survey: Prior to developing a project plan, LMNS should complete a survey to baseline existing local services. This will help establish an understanding of service provision for improvement. A service baseline survey template can be found on the Maternity Programme’s (MNP) FutureNHS workspace here.

Project plan: Each System should have a project plan setting out the local context, vision and aims for the PPHS, objectives and expected outcomes, the project approach, coproduction with service users, and finance and management arrangements. A project plan template can be found on the MNP FutureNHS workspace here.

Project schedule: Alongside the project plan, Systems should develop a project schedule for implementation, which outlines responsibilities and timeframes for key deliverables and milestones. A project schedule template can be found on the MNP FutureNHS workspace here.

Spending plan: Systems will need to use a spending plan to plan for and monitor spend. A spending plan template can be found on the MNP FutureNHS workspace here. These plans should distinguish between implementation spending and ongoing business-as-usual spending. LMNS should seek to ensure that the full rate of funding being allocated to PPHS is accounted for in the ongoing, business-as-usual spending plan. This is set out in the 2023/24 LMNS funding letter.

Please note that since the 23/24 LMNS funding letter in March, NHS England Strategic Finance has published finance and contracting guidance for the AfC pay award, and confirmed a net pay uplift of 1.57% to ICBs for all Service Development Funding (SDF) bundles allocated for maternity in 23/24. This includes Perinatal Pelvic Health Services funding, which is factored into Bundle 1 ‘Maternity: Local Ockenden & East Kent response’, as explained in the March LMNS funding letters.

The pay award uplift is recurrent, and so from 2024/25 will be added to the programme envelope and applied as an uplift to allocations bundles as appropriate. PPHS leads are advised to seek conversations with LMNS leads and ICB finance leads as soon as possible, to discuss the total funding uplift required for PPHS staffing.

A large proportion of pilot systems have experienced delays of up to six months in recruiting to new posts. Systems are advised to agree a ‘Plan b’ or alternative spending plan for years where recruitment for new posts is planned – one-off expenditure could include equipment, technology applications or licences, training and education, service user engagement and coproduction, content development, or other ‘pump-prime’ that would benefit the service longer term. The ‘plan b’ should ensure full use of funding to the benefit of the PPHS if planned recruitment is delayed for up to 6 months. 

1.5.   Service user engagement

The PPHS should be coproduced with local service users. Services should have at least one Service User Voice Representative with lived experience of perinatal pelvic health problems, on the project team and engage with the local Maternity and Neonatal Voices Partnership (MNVP) on a regular basis. PPHS should also conduct outreach work to consult with and listen to a diverse group of service users on the development and continuous improvement of the service. Further, services should ensure they have a feedback mechanism in place for women to provide feedback on the care they have received. PPHS should remunerate service users for their time and expenses in line with local policies.

LMNS should consult the NHS England statutory guidance on Working in partnership with people and communities when planning service user engagement and consider the range of opportunities to do this – such as attending local places where service users gather (baby groups/family hubs), or inviting service users to share their stories, for example.

When working with service users, PPHS should consider:

• Including and consulting service users in meeting preparations, such as agenda planning
• Setting mutual expectations
• Fostering positive relationships and respecting service users as equal members of the team
• Considering accessibility and attendee needs (e.g. meeting somewhere with good public transport links, parking, baby changing and feeding facilities)
• Checking attendee availability and giving enough notice to prepare
• Providing remuneration and expenses (e.g. travel, childcare costs, meals, materials such as printing) in a timely manner
• Considering suitable timings (e.g. allowing time for travel, avoiding school holidays and school run times, holding events in the evenings)
• Giving sufficient time to respond to requests
• Ensuring you have good communication with the service user(s)
• Providing more than one point of contact
• Facilitating engagement with a variety of service users
• The language needs of attendees and enabling women to provide feedback in their own language

1.6.   Planning in view of the national service specification

1.6.1 Early implementer and fast follower PPHS

Early implementer and fast follower PPHS have already made substantial progress towards designing and implementing their local service, but there may be elements of the model set out in the service specification that Systems have not included in their local service model, or have not yet implemented.

Early implementer and fast follower systems will therefore need to carry out a gap analysis to :

• systematically review the local PPHS service model against the standards set out in the national service specification;
• assess current progress with local implementation; and
• identify any gaps or issues.

Depending on the results of this gap analysis, systems will then need to set out either:

• how the service is compliant with the national specification;
• a plan to address any gaps or issues to bring the service in line with the national service specification; or
• why the service will remain non-compliant with the national service specification, including any risks associated with non-compliance and how they will be managed or mitigated.

The gap analysis, proposed outputs and areas of proposed non-compliance should all be signed off by the ICB as the local commissioner of the sustainable PPHS.

A gap analysis template can be found on the MNP FutureNHS workspace.

Early implementers and fast followers are encouraged to share completed gap analysis templates – following sign off from ICBs – with the national Maternity and Neonatal Programme. This is not for the purposes of assurance, but will provide helpful initial feedback from providers and commissioners on the standards of the national service specification.

• PPHS are asked to send completed gap analysis templates to england.pphs@nhs.net by 31 March. 

1.6.2 LMNS without an established PPHS

LMNS that were not early implementers or fast followers will need to develop plans for implementation based on meeting the requirements set out in the national service specification.

These LMNS are advised to develop detailed implementation and spending plans up to at least March 2025, and then high level up to full business-as-usual implementation. Key documentation will need to be completed, as set out in section 1.4. Developing a plan.

It is recommended that these documents are included in the commissioning agreement with the ICB.

1.6.3 Assurance / Oversight of service establishment

LMNS/ICBs will have overall responsibility as commissioners for overseeing the implementation and ongoing operation of the PPHS, and for reporting to NHS England nationally on:

• whether a PPHS has been commissioned (either on an operational or developmental basis) by March 2024 in line with the Three Year Delivery Plan; and
• whether the commissioned PPHS is operational across the ICB footprint.

1.7.   Ongoing support for implementation

1.7.1 Support with planning

Implementing systems seeking a ‘sense check’ or expert review on their draft plans are invited to share them with the national team for constructive feedback.

Draft plans can be submitted to england.pphs@nhs.net any time up to Friday 22 March 2024. Plans shared by 5 January will receive feedback by the end of February. Plans received from February will receive an indicative date for feedback, though please expect to wait 2-3 weeks depending on the availability of SMEs to review.

1.7.2 Drop-in sharing and learning sessions

From September 2023 to March 2024, there will be monthly drop-in sharing and learning sessions organised by the national team to support systems beginning implementation in 23/24. These will include presentations from early implementers and fast followers to showcase their progress and learning and provide opportunities to ask questions and seek common solutions. All members of PPHS project groups are welcome, please email england.pphs@nhs.net to be invited to these sessions.

1.7.3 Regional buddying

Every NHS England region has an early implementer or fast follower system that has already made progress establishing a Perinatal Pelvic Health Service. A list of early implementer or fast follower systems can be found in Appendix A, below.

Project leads beginning this process in 23/24 are encouraged to seek out mentors through their regional maternity teams. However, leads could also contact early implementer or fast follower systems in other regions with shared demographic or geographic characteristics – for example areas with high levels of rurality, or deprivation.

1.7.4 Future NHS platform

There is a dedicated PPHS space on the NHS Futures maternity local transformation hub for systems to share documents, knowledge, and best practice in relation to the development of PPHS. Systems are encouraged to make use of the resources and forums available on this platform, which include:

2. Care pathway and clinical dependencies

2.1 Care pathway

For each element of the care pathway in the service specification, this section sets out:

• Standards in NICE and other national guidelines, or relevant evidence,
• Resources available to support local implementation, and
• Case studies and learning from early implementer or fast follower Systems.

Given poorer reported outcomes for ethnic minority women and those living in the most deprived areas across many aspects of maternity and wider healthcare, Systems should assess the demographics of the local population and inequalities in experience and outcomes for certain groups and ensure these are taken into account in the co-production of the local service offer. An understanding of common local languages (e.g. by analysing data on languages commonly requested from maternity interpretation services) can be useful when planning the service.

2.1.1 Embed evidence-based practice in antenatal, intrapartum, and postnatal care to prevent and mitigate pelvic health problems resulting from pregnancy and childbirth 

a) Routine education about pelvic health problems antenatally and postnatally

Section 2.1.1.a of the PPHS service specification sets out that PPHS will ensure that all women using maternity services in the LMNS footprint receive routine information at regular intervals antenatally and postnatally about perinatal pelvic health care and problems that could arise.

Relevant standards

Ways of meeting the standard

NHS England is commissioning the development of a clinical patient information standard for perinatal pelvic health, which will set out standards and materials for the provision of printed and electronic information throughout the perinatal period.  This will be available in spring 2024. Until this standardised information is available, services should use existing resources.

Classes, workshops, and drop-ins

• Patient education classes or workshops run by physiotherapists and/or midwives.
• Consider holding classes online and in a variety of locations in the community, for example family hubs, baby groups, libraries, village halls, places of worship, museums, and other event spaces.
• ‘Drop-in’ sessions on the postnatal ward for postnatal pelvic health advice. 
• Monitor demographics of women attending events to assess whether all women can access the support.
• Consider offering classes in languages used by the local population.
• Ask attendees for feedback following events to enable improvement, and include demographics questions to monitor access and experience for different groups. Consider linking feedback questions to the KPIs for PPHS.

Leaflets/ posters/ banners/ postcards

• Make digital and paper leaflets available to women accessing maternity care.
• Place posters, banners and digital adverts around relevant clinics, maternity wards, GP surgeries, and community spaces local family centres.
• Add links and QR codes to documentation to signpost service users to relevant webpages and resources.
• Circulate information via social media channels, including local MNVP pages.

Website content

• Put pelvic health information, self-referral and self-assessment forms, and videos on a webpage. Information could be placed on Trust/ICS/LMNS websites, either on a dedicated PPHS webpage or throughout pre-established maternity pages.
• Develop a campaign related to PPHS, such as ‘Squeeze Lift Hold’.
• Use existing patient information, such as those from:
  • Pelvic Obstetric and Gynaecological Physiotherapy (POGP)
  • Royal College of Obstetricians and Gynaecologists (RCOG)
  • British Society of Urogynaecology (BSUG)
  • International Urogynaecology Association (IUGA)
• Collaborate with relevant local webpages and magazines, for example Dorset LMNS worked with Maternity Matters Dorset and Healthier Together and Frimley have worked with the #Readyfor parenthood campaign.
• Publish blogs and newsletters across websites, social media platforms, and via emails.

Videos

• My Health London developed a suite of videos titled Your Body’s Journey During Pregnancy and After Birth. The videos cover the pelvic floor, posture, bladder care, returning to exercise, and supporting the body during and after pregnancy. The videos are freely available in multiple languages.
• Sussex LMNS developed a range of videos as part of their Wellbeing Exercise Pregnancy Programme. There are a range of videos to choose from including pilates, yoga, gym ball, and general exercise.

Mobile applications

• Some LMNS have their own mobile applications or have procured licences to enable women to freely access applications that provide information and education about pelvic health.
• Some areas have purchased tablet computers so staff can demonstrate how to use applications.

Raising awareness

• Work with local groups, charities, and organisations that pregnant and postnatal women engage with, particularly those working with seldom-heard groups.
• Developing a community champions programme
• Hold events on perinatal pelvic health for pregnant and post-natal women, these could be organised in partnership with local organisations.
• Promote information on pelvic health via LMNS and Trust social media pages and consider aligning activities with events and campaigns such as World Continence Week and Prolapse Awareness Month, which are both in June.

b) A baseline self-assessment of pelvic health at around booking and postnatally

Section 2.1.1.b of the PPHS service specification sets out that the PPHS will work with maternity services to ensure that all women are offered a self-assessment of their pelvic health as early as possible in pregnancy – by 18 weeks. The PPHS will engage with primary care to encourage offer and signposting of the assessment at the postnatal GP check, so that women with identified problems can be referred for specialist support as appropriate. Assessments can be repeated later in antenatal and postnatal care to identify issues that arise and assess any deterioration in pelvic floor function.

Relevant evidence

NICE recognises incontinence is likely to be ‘significantly underreported’ because women can be ‘embarrassed to seek advice’.[1] A 2019 Kings Fund report reported that women delayed seeking medical help due to embarrassment or a perception that pelvic health problems are not a health concern[2] and a 2017 National Childbirth Trust survey found that 38% of women were self-conscious speaking about incontinence with a health professional.[3] It is therefore expected that the introduction of a pelvic health assessment tool that is used routinely in maternity care will help improve rates of early identification and referral to treatment. It is additionally anticipated that asking women to complete an assessment tool in pregnancy will raise awareness of the key symptoms and empower women to seek specialist treatment when needed.

Ways of meeting the standard

The service specification sets out that NHS England has commissioned the development of a perinatal pelvic health self-assessment tool which will be clinically validated and available in the summer of 2024. An unvalidated version is expected in 2023. Services can deploy the tool in unvalidated form or develop their own assessment questionnaires on an interim basis until the validated version is available.

PPHS should work with midwives to ensure all women are offered the opportunity to use the tool by 18 weeks antenatally and engage with GPs to encourage its use at the postnatal six-to-eight-week check. Women should also be encouraged to use the tool at any point in the perinatal pathway if symptoms develop.

Services should consider the most appropriate and effective ways to share and encourage service users to complete the tool. It might be offered to women on a leaflet or postcard with a link or QR code, or electronically via a mobile application. Services should consider a range of opportunities to remind women to complete the self-assessment, for example if a woman attends a smear test within one year postnatally.

Results from the self-assessment tool should be stored in maternity records, and shared with the woman’s GP so that they are available long-term.

Services should further consider whether the results of assessments at specific points in the perinatal pathway could be used for the evaluation of clinical outcomes, as well as to evaluate the effectiveness of antenatal pelvic floor exercises and other interventions.

c) Advice and encouragement to begin pelvic floor exercises (PFE) antenatally, and support to continue throughout perinatal care

Section 2.1.1.c of the PPHS service specification sets out that PPHS will work with maternity services to ensure that women are given information and training as early as possible in pregnancy on how to do PFE and throughout routine antenatal care. Women should be advised to do PFE and that it helps prevent symptoms of pelvic floor dysfunction in pregnancy, postnatally and in later life. PPHS will also work with maternity, primary care and health visiting services to make sure that during routine postnatal care women are reminded of how to do PFE, when to resume PFE and advised to do so.

Relevant standards

Ways of meeting the standard

PPHS should consider the range of opportunities to encourage women to do PFE. Information on PFE should be included as part of antenatal and postnatal information and education (see section 2.1.1.a), but it is known that provision of information alone is generally insufficient to support long-term behaviour change.[4] Antenatal PFE should therefore ideally be delivered through a structured training programme with individual instruction[5] . Where delivering an individual programme is not possible, an alternative way to meet this standard could be the use of group based PFE classes.[6]

Advice on how to do PFE can be provided by midwives, physiotherapists, health visitors, GPs, or appropriately trained support workers, but these staff groups will need to receive tailored training and support from specialist physiotherapists to ensure they have the competency to provide this support (see section 2.1.2.a).[7]

PPHS may want to consider other innovative approaches for encouraging women to do PFE, including:

• Regular check-ins: These could be via telephone or as group classes.
• Discussing PFE at every contact: To normalise the conversation and remind women to do PFE.
• Use of exercise diaries: These could be recorded in notes to help monitor compliance.
• Using mobile applications and social media: Some PPHS have used electronic notifications on the local maternity app to ‘nudge’ women to do PFE. There are also mobile applications available to support women with PFE.
• Using evidence on behaviour change: to inform the PFE education intervention and promote PFE as a lifelong habit.

Additional support for those who need more time to learn how to perform PFE correctly could include:

• A group class or one-to-one appointment. These could be either in-person, via telephone or online, but at least one in-person appointment is good practice to ensure comprehension of the exercises and technique.
• Women with lower English-language fluency could be offered a telephone consultation via mobile language services, a one-to-one appointment with an interpreter, or a group class in their own language.

d) Additional support for those identified as at higher risk of issues

Section 2.1.1.d of the Service Specification sets out that PPHS should provide targeted specialist preventative support and interventions for women identified as being at greater risk of pelvic health problems. This should include adopting shared standards and protocols for identifying pregnant women considered at greater risk.   PPHS should consider providing additional preventative support for these women, which could include one to one or group classes (in-person or online).

Relevant standards

Ways of meeting the standard

Some women may benefit from targeted specialist support in the antenatal period to reduce their risk of developing pelvic health issues, this may include women with modifiable and non-modifiable risk factors for pelvic floor dysfunction, including those related to labour and birth[8]

PPHS may consider introducing a risk assessment approach to assess whether additional support is required. NICE Guidance sets out key risk factors for pelvic floor dysfunction.[9] Several tools are also available to predict who is at higher risk of pelvic floor dysfunction, including the UR-CHOICE Pelvic Floor Disorders Risk Calculator which has been developed to help model the long-term risk of urinary incontinence, prolapse and anal incontinence after vaginal birth and caesarean.[10] NICE guidance concluded that there was insufficient evidence to recommend a specific tool.[11]

PPHS may also want to use a targeted approach to provide support to communities that are disproportionately affected by health inequalities within their local population.  

Additional support for those identified to be at greater risk of pelvic health problems could be provided one-to-one or in small groups, and in-person or online. As well as physiotherapists, specialist midwives and midwifery and physiotherapy support workers could be trained to provide this support depending on the level of support required.

e) Adopt practice to mitigate the risks of obstetric injury during birth, and provide quality wound care

Section 2.1.1.e. of the Service Specification sets out that PPHS will work with maternity services to review and improve obstetric and midwifery practice to minimise the risk of obstetric injury during birth (including perineal tears, bruising and birth trauma) and provide quality wound care in line with NICE Guidance. In particular, PPHS will work with maternity services to implement the OASI Care Bundle to reduce rates of obstetric anal sphincter injury (OASI).

Relevant standards

Ways of meeting the standard

The OASI Care Bundle is a bundle of interventions developed by the RCOG & RCM that support clinical practice to prevent obstetric anal sphincter injuries (OASI) resulting from labour and vaginal birth. An analysis of the effectiveness of the OASI Care Bundle based on over 50,000 vaginal births, found that women’s risk of OASI decreased by 20%.

The OASI Care Bundle emphases good communication with the woman and a slow and controlled birth with the following components:

• Antenatal discussion about OASI and what can be done to reduce risk
• Manual perineal protection while communicating with the woman to encourage a slow and guided birth
• If clinically indicated, mediolateral episiotomy should be performed at an angle of 60 degrees from the midline at crowning
• Systematic examination of the vagina and ano-rectum even if the perineum appears intact[12]

Maternity services must lead on work to achieve compliance within their units.  Materials to implement the OASI Care Bundle materials are available on the eLearning platform on the RCOG website. To access the resources, visit the RCOG Learning homepage and click ‘Login’ in the top right corner. If you don’t already have an RCOG Learning account, you will need to create one by clicking ‘Register Now’ and entering some basic details. Once you have created an account you will automatically have access to the OASI Care Bundle Set, which contains the following three modules:

1. Practical training for clinicians contains bite size skills training videos, the OASI Care Bundle manual, antenatal discussion guide, and more. Once registered, you can access the OASI Care Bundle course 1.
2. Implementation resources for local leads contains additional resources to support those introducing or sustaining the OASI Care Bundle in their maternity services. Once registered, access the OASI Care Bundle course 2.
3. Full tutorial for professional development credit is a comprehensive course that includes the background and development of the OASI Care Bundle, as well as evidence for and practical application of the four components. Once registered, access the OASI Care Bundle course 3.

RCOG & RCM have also developed an antenatal information animation, which complements and covers much of the same information as the OASI2 antenatal discussion guide. Translations are available for 12 languages to accompany the animation, which will improve the accessibility of this information to speakers of other languages. You can view the animation on the OASI Care Bundle webpage or via the first module on RCOG Learning listed above. All versions of the animation will be accessible via the Tears Hub by the end of 2023, when it is being updated.

The following minimum indicators set out what is required for a maternity service to be compliant with the OASI Care Bundle:

• One midwife and one obstetrician to be appointed as specialist leads for local OASI Quality Improvement (person specifications provide guidance on how to select an adequate candidate and role expectations). These leads require protected time to support and initiate roll-out, for ongoing facilitation of training sessions and local audit and feedback. Local PPHS leads with protected time could use their time to engage in OASI Care Bundle implementation efforts.
• Ensure that resources to support antenatal discussions with women about tears are made available, along with other informational resources for use during third trimester antenatal care appointments.
• Allow sufficient time for skills training specific to all four components of the OASI Care Bundle on annual mandatory, multidisciplinary training sessions. Training can be incorporated into PROMPT and perineal suturing training.
• Ensure at least 90% of maternity staff participate in annual OASI Care Bundle skills trainings.
• Ensure that local OASI rates are addressed in Board discussions about the local maternity dashboard.
• Monitor local OASI rates each month against most up to date quarterly reporting figures published by the National Maternity and Perinatal Audit.

Additional desired compliance indicators:

• Ensure that the local maternity information system allows clinicians to tick whether a discussion about perineal health took place in the third trimester of pregnancy and/or in the first stage of labour.
• Ensure a baseline of 90% of women and pregnant people not planning an elective caesarean receive information about tearing in the third trimester of pregnancy and/or in the first stage of labour.

The OASI Care Bundle was designed to be implemented in NHS maternity units at little to no additional cost to the service and the training resources referred to are freely available. There are a few potential costs that may need to be considered, depending on how the local service operates:

• Protected time for one obstetric lead;
• Protected time for one midwifery lead;
• Printing of leaflets; and
• Addition of new fields to the local maternity information system.

2.1.2. Improve the rate of identification of pelvic floor issues antenatally and postnatally

a) Provision of training and information for relevant staff groups

Section 2.1.2.a. of the Service Specification sets out that PPHS will engage with relevant staff groups to embed training on perinatal pelvic health in line with the indicative standards set out in the Core Capabilities Framework for Perinatal Pelvic Healthcare [hyperlink to be added on publication]. In addition to maternity staff, PPHS should engage with key primary care staff, health visitors and any other relevant groups across the LMNS that see women perinatally. This will include conducting outreach, education, and training events as required, led by specialist physiotherapists or specialist midwives.

The PPHS will raise awareness amongst these staff groups of available patient information (see section 2.1.1.a), assessment tools (see section 2.1.1.b) and the single point of access (see section 2.1.3.b). 

Relevant standards

Ways of meeting the standard

When developing training, education and learning packages, PPHS should refer to the Core Capabilities Framework for Perinatal Pelvic Healthcare [to be added on publication], which describes the knowledge, skills and behaviours which the healthcare workforce needs to apply in order to provide high quality, compassionate, personalised perinatal pelvic healthcare. The framework determines standards for perinatal pelvic health education and training and assists in measuring whether education and training satisfies these standards. The Framework should be used to guide the key outcomes and content of training, as well as teaching, learning and assessment strategies.

PPHS should consider the range of staff that could be trained in pelvic health. For example, Birmingham and Solihull have offered training for Midwifery Link Supporters, who have been employed to support women for whom English is not their first language.

It is recommended that training is provided regularly to refresh staff and ensure new starters receive training.

PPHS can utilise existing training programmes set out in the table below or develop their own trainings for local healthcare staff. Some PPHS have managed to integrate pelvic health training into existing mandatory training, such as suturing or OASI training. Some areas have also set up regular webinars on pelvic health with guest speakers from the multidisciplinary team.  

When planning and allocating resources, consideration will need to be given to staff capacity to deliver ongoing training.

It is recommended that after carrying out education and outreach activities, PPHS consider ways of measuring the impact of the training, for example whether those healthcare professionals are offering advice, the impact of this and how onward referrals are made.

b) Follow-up for women who have experienced risk factors for pelvic health problems during birth

Section 2.1.2.b. of the service specification sets out that PPHS will agree shared pathways and protocols for follow-up for women who have experienced risk factors for pelvic health problems during birth, including but not limited to: assisted vaginal birth (forceps or vacuum/ventouse), a vaginal birth when the baby is lying face up (occipito-posterior), and injury to the anal sphincter (perineal trauma and tears).

Relevant standards

Ways of meeting the standard

Services should develop shared protocols and pathways for the follow-up of women who experience risk factors because of the birth they experienced, these may include:

• Provision of information and advice on recuperation, what to expect, initiation of pelvic floor exercises, and signs and symptoms to look out for. This could be on the postnatal ward or as a postnatal phone call.
• Postnatal screening for risk factors and symptoms.
• Follow-up at defined points for women with specific risk factors, for example for women who experience injury to the anal sphincter.
• Physiotherapy visits on the postnatal ward.
• Postnatal ward Pelvic Heath Champions.
• A supervised and personalised PFE programme.
• Postnatal group PFE classes.

Refer to section 2.1.1.d for potential methods for identifying risk.

2.1.3. Ensure timely access to NICE-recommended treatment in inpatient and outpatient settings for common pelvic health problems antenatally and postnatally

a) Specialist physiotherapy treatment for pelvic health problems in line with NICE Guidance

Section 2.1.3.a. of the Service Specification sets out that PPHS will ensure that women with symptoms of pelvic health problems have access to appropriately timed pelvic health physiotherapy assessment and treatment – including specialist physiotherapy – in line with NICE Guidance. The service should be available to all women antenatally and for at least 12 months postnatally.

The PPHS will ensure that conservative management is always discussed before surgical interventions are offered. PPHS should develop shared standards for which women will require urgent care and what constitutes ‘appropriately timed’ care, in view of NHS waiting time standards, as set out in the NHS Constitution handbook.

The PPHS is intended to supplement – and not replace – existing pathways and capacity. Where pathways and capacity are already in place to deal with any ‘in scope’ conditions – for example, pathways to support pelvic girdle pain, rectus abdominis diastasis, or suspected cauda equina in pregnancy – these should continue, with the PPHS playing a co-ordinating / referring role.

PPHS should aim to provide care as close to a woman’s home as possible, and ideally services would be located in the community, for example in community hospitals or family hubs. PPHS should also consider opportunities to work with other community-based teams, such as continuity of carer and infant feeding teams. It is important that services are accessible, particularly for those most likely to face health inequalities. This may mean offering consultations in-person, by video or over the phone.

The PPHS should monitor the demographics of women using the PPHS against the demographics of the local population to assess whether it is being accessed at an equitable rate.

Relevant standards

b) A single point of access for PPHS

Section 2.1.3.b. of the service specification sets out that the PPHS will operate a single point of access (SPoA) across the LMNS footprint, to streamline the referral process and ensure that both conservative support and treatment and – where required – referral for surgical management is available in a co-ordinated, timely manner.

Where one single point of access is not feasible across the LMNS footprint (for example, due to a lack of digital interoperability), standardised points of access can be established across the footprint. In this case, every point of access must work to shared standard operating procedures (SOPs), with individual monitoring/review to ensure equal service provision and standards across the System. The number of standardised points of access should be kept to a minimum to reduce complexity and decision making for signposting professionals and women. Obstacles to establishing a SPoA should be raised in the appropriate issues log and kept under review, with a view to future resolution. 

Background and rationale

An SPoA is defined as single point of referral (both clinician and self-referrals) for access to all services and support for women with perinatal pelvic health problems across all providers within the local system. 

There has been considerable variation nationally in terms of how women access specialist support and unclear or complex protocols on how to refer women for specialist treatment can result in significant waiting times. Establishing an SPoA is expected to reduce uncertainty for referring clinicians, streamline access to specialist support and give women more confidence in the service offer.

Ways of meeting the standard

In the design and establishment of a local SPoA, PPHS will need to consider:

• Estimated demand, by looking at data on the number of providers and maternity sites in the footprint, the number of births and risk factors for pelvic health across the local population, and existing provision of physiotherapy services for women in the perinatal period.
• Where overall management of the SPoA will sit, this may involve selecting a provider to host it.
• Resources required to maintain the SPoA, including administrative time and the pelvic health physiotherapy workforce.
• How triage will be managed and where to signpost women who do not meet the criteria.
• How the SPoA is accessed – this is commonly via a webpage – and to ensure it is accessible for all.
• How to enable information transfer between providers.
• Digital maturity of local services and technology requirements for the SPoA, for example whether existing systems can be used or if a bespoke solution is required, and the interoperability of electronic systems.
• How the SPoA will be implemented, for example whether rollout will be phased. Some areas have found it beneficial to develop an SPoA at provider level initially to ensure integration with existing services, before scaling it up to LMNS-level.

c) Reduce referral to treatment times by streamlining referral processes

Section 2.1.3.c. of the service specification sets out that the single point of access should accept self-referrals alongside clinical referrals to reduce waiting times and minimise administrative barriers to treatment. The ability to self-refer should be made available to women antenatally and for at least 12 months postnatally. A clinically validated assessment tool (as specified in 2.1.1.b) can be linked to the self-referral process to ensure self-referrals are appropriate and to facilitate triage.

Background and rationale

Self-referral empowers women to seek help, provides easier access to services, increases patient satisfaction, and promotes equality of access.[15] Pelvic floor problems are thought to be significantly under-reported due to embarrassment and concerns with speaking about incontinence with a health professional.[16]  Self-referral helps address this by reducing the number of clinicians that a woman needs to speak with. In addition, linking a self-assessment tool to self-referrals could help give confidence or ‘permission’ to seek help, for those who are unsure whether they have an issue warranting clinical attention.

Ways of meeting the standard

PPHS will need to ensure they have adequate administrative support and digital infrastructure to manage self-referrals.

Sites that have concerns about the numbers of referrals could phase implementation and complete pilot testing to assess the likely caseload, time required, and admin input needed to support self-referral.

Self-referral forms and pathways should be coproduced with relevant healthcare professionals and service users. Accessibility needs should be considered, including the use of simple-language, translations, and a paper and/or phone-based self-referral process for those who are unable to access digital technology.

Sites should consider use of a self-assessment tool to facilitate self-referrals, which will help to ensure referrals are appropriate and aid triage.

PPHS will need to put in place a communications strategy to raise awareness of the self-referral facility, to include engagement with health professionals and community groups. Efforts should be made to engage groups most likely to experience health inequalities.

d) Leadership in the local planning, provision, and improvement of perinatal pelvic health care

Section 2.1.3.d. of the service specification sets out that the PPHS will lead and collaborate in the planning, provision, and improvement of perinatal pelvic health care across providers, specialities, and community services in the local Integrated Care System (ICS).

Relevant standards

Ways of meeting the standard

The improvement of pelvic health care perinatally requires the involvement of professionals working in midwifery, physiotherapy, obstetrics, gynaecology and urogynaecology, colorectal, primary care, health visiting and family hubs, and service user representation.

As part of workforce planning, PPHS should consider the leadership required to ensure multidisciplinary working and to provide training across PPHS footprints. Leadership should facilitate whole system working and enable coordination across both providers and services to ensure referral pathways are seamless across all services available to all women.

As this service is new and developmental, quality improvement strategies and change management strategies will need to be implemented by the service team to support the improvement of care.

2.2.   Co-dependencies with other services

Maternity and physiotherapy

PPHS will need to ensure integration and collaboration across both maternity and physiotherapy services.

PPHS will need to consider pathways and integration between existing services and the PPHS, for example how duplication of referrals with existing physio teams will be avoided.

PPHS should work with commissioning leads, clinical leads, and provider service managers to ensure that there is awareness and understanding of the provision and how to refer or access the service. PPHS will also need to work with the maternity and physiotherapy workforce to raise awareness of these new services, particularly among midwives and obstetricians.

Early in implementation, PPHS should seek to identify:

• The overall LMNS lead, LMNS women’s and children’s and physiotherapy leads, and the LMNS digital midwife
• Trust women’s and children’s and physiotherapy directors and service managers
• Matrons in maternity for community, intrapartum and inpatient care.
• Maternity leads for clinical governance, patient safety, patient experience, audit, and practice development.

Gynaecology, urogynaecology and colorectal

As set out in the Service Specification, PPHS should build on existing services, broadening the service offer beyond OASI care, but will need to consider pathways and integration with gynaecology, urogynaecology and colorectal services. PPHS will therefore need to work closely with and have representation from relevant medical specialties on the multi-disciplinary team. It is recommended that PPHS identify local ICS clinical and workstreams leads for gynaecology, urogynaecology and colorectal services.

Primary care, health visiting, and family hubs

PPHS will need to work with primary care, health visiting and other local services that work with women in the perinatal period, including family hubs and community-based services, such as community musculoskeletal and continence services.

Women’s Health Hubs also present an opportunity to align perinatal pelvic health care with other pathways in the community.

It is therefore recommended that PPHS identify local ICS primary care leads, ICS health visiting leads, and leads for other relevant community-based services, including Women’s Health Hubs. It is also recommended that PPHS make contact with the local authority public health team, who may also be able to help with finding community spaces.

Mental health services

Section 2.2. of the service specification sets out that PPHS should establish links with mental health services, particularly maternal mental health services, perinatal mental health services and psychosexual counselling services, to ensure effective signposting and referral between pelvic and mental health care and vice versa.

Voluntary, Community and Social Enterprise (VCSE) groups

A wealth of VCSE groups and other organisations offer support across the country to women on pelvic health, though this varies from area to area.  PPHS should therefore engage with VCSE groups from an early stage, as a means to gain service user input, raise local awareness of the PPHS service offer, but also where appropriate to signpost for additional community support.

Relevant standards

Ways of meeting the standards

PPHS and relevant Mental Health Services need to know about each other so that they can signpost to one another. PPHS Leads should therefore identify leads for relevant local mental health services.

There may also be opportunities to collaborate in other ways, for example, the services may work together by attending multidisciplinary team meetings, arranging cross-service training, sharing resources, and holding joint events and classes.

2.3 Staffing

Section 2.3. of the Service Specification sets out that the PPHS will ensure that there is defined dedicated clinical establishment within the multi-disciplinary team to carry out the key functions of the service. This will be based on analysis of local needs; however, at a minimum, dedicated specialist capacity for the PPHS should include:

• A lead Specialist Pelvic Health Physiotherapist (recommended Band 8a or above)
• Pelvic Health Physiotherapists
• A Specialist Pelvic Health Midwife or Midwife with a special interest in pelvic health (Recommended Band 7 or in line with local requirements)
• Administrative support

Recommended bandings have been indicated for some posts, based on early roll out experience. However, it is for local systems to determine what staffing is required to deliver the PPHS objectives and the local vision and plan to improve care. Services might consider recruiting additional staff, for example Physiotherapy or Maternity Support Workers (Bands 3 – 4).

Ways of meeting the standard

When setting up the PPHS, an assessment of existing staffing should be carried out as part of the baseline survey. The results of this assessment should feed into staffing plans to ensure that they are aligned with existing staffing and structures. Services should then consider what additional positions are required, in line with the roles set out above. It is recommended that services have positions in a mixture of bandings to create opportunities for career progression.

PPHS physiotherapy and maternity staff should have protected time and clinical spaces to run the service.

It is important that PPHS ensure there is adequate supervision and support for specialist staff so that training, workforce growth, retention and satisfaction are addressed. PPHS should particularly consider training and development needs to support the development of staff in lower bands, including ongoing placements in local junior (ie Band 5 and 6) physiotherapist rotations, and offering student physiotherapy placements wherever possible. PPHS may also want to consider arranging mentorship for junior pelvic health physiotherapists within pelvic health teams.

PPHS should consider carrying out reviews of service demand against available capacity on a regular basis, particularly during the implementation phase.

2.4 Service governance and leadership

The service specification sets out that the PPHS should be jointly led by maternity and physiotherapy services, with joint oversight including regular review of service KPIs, risks and issues, in both Women’s and Children’s and Therapies’ governance.

Ways of meeting the standard

The pelvic health physiotherapy lead needs to ensure that they meet with the head of midwifery and clinical director of obstetrics and gynaecology at all Trusts within the LMNS. The PPHS lead should support with clinical governance and guideline groups and when necessary be invited to divisional director meetings. Therapy managers should also ensure the pelvic health physiotherapy lead is invited to therapy senior management meetings.

The PPHS should provide regular governance reports to maternity services on all acute Trusts within the LMNS to maintain equitable care for women across all providers.

Risk should be managed through existing maternity pathways and the pelvic health physiotherapy lead should be present at maternity risk meetings. Therapy services that may have management of the PPHS physiotherapy staff also need to be informed of any risk within the service to support with investigations.

Shared responsibility needs to be maintained across both maternity services and therapy services for recruitment and training of PPHS staff. Workforce planning should be completed collaboratively to ensure adequate multi-professional support is provided.

The lead should liaise with therapy training providers to ensure that postgraduate training opportunities are available for post-registration physiotherapy training. Pelvic health representation should be present within the training needs analysis for physiotherapists, coordinated by the PPHS lead and informed by identifying gaps in workforce planning. The PPHS lead themself may benefit from leadership training.

2.5 Clinical settings

Section 2.5. of the service specification sets out PPHS should identify and establish treatment rooms in outpatient care settings, to provide care as close as possible to women and in the community where possible, such as in primary care premises, community hospitals or in family/community hubs. PPHS should also consider opportunities to work with other community-based teams, such as continuity of carer and infant feeding teams.

Services will need to consider their facilities requirements and should involve the local estates team early in the development of the service. PPHS should also ensure both service user and staff considerations are taken into account when identifying suitable locations.

Women’s Health Hubs also present an opportunity to align perinatal pelvic health care with other pathways in the community. PPHS leads should identify those within their ICB with responsibility for establishing these hubs, to identify opportunities and encourage alignment with Perinatal Pelvic Health Services from early planning.

3. Key Performance Indicators (KPIs)

Continuous monitoring of the service through KPIs is necessary to assess whether the service is delivering the expected level of care and benefits. PPHS will therefore need to monitor the services against KPIs set out in the Service Specification.

The KPIs include two types of measures, process measures and outcome measures. Process measures indicate whether key systems and processes are in place to achieve the anticipated outcomes. Some of the process measures are patient reported experience measures (PREMs), which reflect service user perceptions and satisfaction with the service. The outcome measures show that the system is working, i.e. that the service is improving patient outcomes as expected.

PPHS leads should use the KPIs to baseline service delivery and track improvements against this. The KPIs can also be used at both a local and national level to compare different geographical areas.

There are two sources for the KPIs:

1. Locally collected: KPIs that are collected and monitored locally for local service improvement.
2. Nationally collected: KPIs that are collected using routine national data and will be placed on national maternity dashboards and monitored nationally.

The full and detailed definition and calculation for each KPI is set out in Annex 2: Perinatal Pelvic Health Services KPIs.

Locally collected PREMs should be measured by surveying women. KPIs 2, 5, 6, and 7 should be measured by surveying women who have used maternity services within the last year. KPIs 11 and 14 should be measured by surveying women that have used the PPHS. The questions set out in Appendix A will need to be used to measure these KPIs, but services can add other questions as required for local service improvement.

PPHS should co-produce and publish a survey with the multi-disciplinary team and service users, provide it to service users (samples should be random), gather responses, and store and analyse the data in compliance with local information governance policies. Services will need to consider accessibility requirements to ensure that all women have the opportunity provide feedback, this should include ensuring that surveys are translated into local languages.

Most areas have used electronic systems, such as Microsoft Forms or BadgerNet to collect responses, but paper versions should also be available for those who are unable to access the surveys digitally.  Pilot services have used a variety of methods to survey maternity service users, including asking midwives and health visitors to share links/QR codes and copies of the survey, and by having information about the survey on the postnatal ward. Surveys of PPHS users should be shared at discharge from the service. Example surveys can be found on the NHSFutures page.

4. Appendix A: Early implementers and fast followers

Early Implementers

• Birmingham and Solihull
• Bristol, North Somerset, South Gloucestershire
• Cornwall and the Isles of Scilly
• Dorset
• Frimley
• Herefordshire and Worcestershire
• Hertfordshire and West Essex
• Lancashire and South Cumbria
• Norfolk and Waveney
• North West London
• Shrewsbury, Telford and Wrekin
• South East London
• Suffolk and North East Essex
• Sussex

Fast followers

• BaNES, Swindon and Wiltshire
• Bedfordshire Luton and Milton Keynes
• Black Country and West Birmingham
• Cambridgeshire and Peterborough
• Cheshire and Merseyside
• Devon
• Gloucestershire
• Mid and South Essex
• North Central London
• North East London
• Somerset
• South West London
• South Yorkshire and Bassetlaw
• Staffordshire and Stoke-on-Trent

References

[1] NICE QS77

[2] Ross, S. Baird, B. Women’s experience of gynaecological and urogynaecological services in primary and secondary care. The King’s Fund 2019

[3] NCT, ‘The Hidden Half’, June 2017

[4] Horne R, Clatworthy J. Adherence to advice and treatment, in: French D, Vedhara K, Kaptein A, Weinman J, editors. Health Psychology. 2nd ed. Chichester. Blackwell Publishing Ltd; 2010: 175-188

[5] Bø K, Haakstad LA. Is pelvic floor muscle training effective when taught in a general fitness class in pregnancy? A randomised controlled trial. Physiotherapy. 2011 Sep;97(3):190-5. doi: 10.1016/j.physio.2010.08.014. Epub 2011 Feb 4. PMID: 21820536.

[6] Brennen R, Frawley HC, Martin J, Haines TP. Group-based pelvic floor muscle training for all women during pregnancy is more cost-effective than postnatal training for women with urinary incontinence: cost-effectiveness analysis of a systematic review. J Physiother. 2021 Apr;67(2):105-114. doi: 10.1016/j.jphys.2021.03.001. Epub 2021 Mar 23. Erratum in: J Physiother. 2021 Jul;67(3):161. PMID: 33771484

[7] Pelvic floor muscle training for women with pelvic organ prolapse: the PROPEL realist evaluation – PubMed (nih.gov)

[8] Pelvic floor dysfunction: prevention and non-surgical management (nice.org.uk)

[9] Overview | Pelvic floor dysfunction: prevention and non-surgical management | Guidance | NICE

[10] Jelovsek JE, Chagin K, Gyhagen M, et al. Predicting risk of pelvic floor disorders 12 and 20 years after delivery. Am J Obstet Gynecol. 2018;218:222 e221-222 e219

[11] Overview | Pelvic floor dysfunction: prevention and non-surgical management | Guidance | NICE

[12] OASI | RCOG

[13] May be available more widely

[14] According to the Core Capabilities Framework for Perinatal Pelvic Healthcare [hyperlink]

[15] pd105_womens_health_self_referral_pilot_project_report_2013_0.pdf (csp.org.uk)

[16] Ross, S. Baird, B. Women’s experience of gynaecological and urogynaecological services in primary and secondary care. The King’s Fund 2019

NCT, ‘The Hidden Half’, June 2017