Let’s Work Together: When and Why to Refer to Women’s Health Physical Therapy

Let’s Work Together: When and Why to Refer to Women’s Health Physical Therapy

Women’s Health Physical Therapy as a Referral Avenue for Nurse-Midwives for their Pregnant and Post-partum Patients

Lorna Troost, SPT

 

The Why

Morbidities within the scope of physical therapy practice are common in the prenatal and post-partum periods, but many other health professionals are not aware of Women’s Health physical therapy (WHPT) as a possible referral avenue. As a health care system, we are not doing all we can to improve the health and wellness of our population if we can’t refer appropriately. The aim of this Capstone is to provide information on WHPT as a possible referral avenue for their patients to East Carolina University nurse-midwifery students.

 Introduction

With the exception of those that affect the health of the baby, many of the morbidities and health concerns that pregnant and post-partum women commonly experience go under-reported and under-treated in American health care.⁵ Most of the modern obstetrical literature focuses on maternal and neonatal mortality and life-threatening illnesses, not the “hidden morbidity” of childbearing.⁵ Morbidity is very common with pregnancy. As much as 80% of women in the third trimester will complain of pain or functional limitations, and at least 45.5% of women report at least one symptom in first year post-partum, including back pain, urinary incontinence, or pelvic pain.⁵ More than a third of women will experience post-partum stress urinary incontinence, with even more experiencing incontinence antenatally.³ Few women will seek treatment, and even fewer medical professionals will ask.⁵ Many women who do bring up functional limitations or pain with their providers will be told to wait and see how things progress, with the belief that discomfort is inevitable but transient. Many of the women who experience early post-partum functional limitations will continue to have them well after child birth. For many women, these issues can become chronic and can have a significant impact on the functional independence, quality of life, and health status of women during the pre- and post-partum periods. Without treatment, many are linked to a decrease in physical activity and quality of life, which can have long-lasting and significant repercussions, such as depressive symptoms, heightening the need for safe, timely, and effective medical care.⁵

Antenatal and post-natal morbidity is under-reported and under-treated, yet many of the most common morbidities have many evidence-based treatments available. Unfortunately, many providers often don’t know about these treatments, or to whom to refer. Interdisciplinary care can help provide the best outcomes to our patients possible, but other health professionals can’t refer to physical therapy if they don’t know what PTs can provide. Some conditions may be able to be treated effectively in an outpatient orthopedic physical therapy setting, a profession which may be better known to other primary care providers, though many outpatient orthopedic physical therapists I have talked to report feeling uncomfortable treating pregnant women. For these and other conditions, Women’s Health physical therapists are appropriately trained and skilled to provide necessary care to improving the function and quality of life of pregnant and post-partum women. Women’s Health physical therapy (WHPT) is a specialization within physical therapy dedicated to the promotion of the health of men and women throughout the lifespan, and includes the treatment of incontinence, pelvic/vaginal pain, prenatal and postpartum musculoskeletal pain, osteoporosis, lymphedema, chronic pain, and more.⁴

Certified nurse-midwives (CNM) are licensed, independent health care providers with prescriptive authority, and are defined as primary care providers under federal law. CNMs provide a wide range of care, including reproductive and primary care, as well as attending births. Nationwide, there are 11,192 CNMs, and are providing an increasing percentage of health care, including attending 7.9% of all US births in 2012.² A third of CNMs identify primary care as their main responsibility in their full-time position, including providing annual exams, writing prescriptions, patient education, and reproductive health visits.²

The process

I began looking into the topic of WHPT as part of interdisciplinary care for pregnant and post-partum in Evidence Based Practice II (PHYT 752), with a literature search on pelvic floor muscle training for pregnant and post-partum women with urinary incontinence, looking at short and long-term outcomes. My PICO question was:

Are short-term conservative management techniques (pelvic floor muscle training) during pregnancy or within 1 year following childbirth effective at reducing urinary incontinence for women more than 1 year following childbirth?

This question led to the creation of a Critical Appraised Topic (CAT), and used in the creation of an informational presentation as part of the Capstone course (PHYT 854). In PHYT 854, I’ve expanded my search to a wider variety of pathologies and conditions common to pregnant and post-partum women, which can be and are often addressed in an outpatient Women’s Health physical therapy setting. This lead to the creation of 3 additional evidence tables.

Products

Based on feedback from current ECU nurse-midwifery students, I selected 4 common morbidities in pregnancy and the early post-partum period upon which to base an educational presentation. This led to the creation of evidence tables and an educational VoiceThread presentation for ECU nurse-midwifery students. Despite the fact that CNMs represent a rapidly growing portion of primary care in North Carolina, ECU has the only nurse-midwifery program currently in the state. The VoiceThread presentation will be shared with current students to provide information about which common conditions their future patients may experience can be improved or alleviated by care from a WHPT, and how to use WHPTs as a possible referral avenue for their patients.

• The Critically Appraised Topic
• The evidence tables
• The VoiceThread presentation (for UNC affiliates)
  • For non-UNC affiliates, the presentation can be viewed here or via Youtube.  Unfortunately, the imbedded links will not work via these methods.

 Evaluation

To evaluate the presentation, I created a student survey. This survey will provide valuable feedback regarding the educational needs of students and how to improve the educational materials to best represent WHPT to nurse-midwifery students as a possible referral avenue. Please click here to take the survey.

My self-assessment, based on feedback I have received thus far, can be found here.

Acknowledgments

I’d like to thank my committee members Melissa Poole and Jennifer Harrington, as well as my advisor Prudence Plummer for all their advice, assistance, and confidence in me. Thank you also to Rebecca Bagley at ECU who was so welcoming and helpful, and open to my Capstone project. I’d like to thank all those at ECU who initially took my survey, and those who have or will watch my presentation and have or will give their feedback, with which I will hopefully be able to create a more useful and informative presentation for future classes.

 

References

1. American College of Nurse-Midwives. Essential facts about midwives. Updated Mary 2014. Available at: http://www.midwife.org/ Essential-Facts-about-Midwives. Accessed March 8, 2015.

2. Martin JA, Hamilton BE, Osterman MJK, Curtin, SC, Mathews TJ. Births: Final Data for 2012. National Vital Statistics Reports; Vol 62, No 9. Hyattsville, MD: National Center for Health Statistics. 2013.

3. Reilly ET, Freeman RM, Waterfield MR, Waterfield AE, Steggles P, Pedlar F. Prevention of postpartum stress incontinence in primigravidae with increased bladder neck mobility: a randomised controlled trial of antenatal pelvic floor exercises. BJOG. 2014 Dec;121 Suppl 7:58-66.

4. Section on Women’s Health. About us. Available at: http://www.womenshealth apta.org/about-us/mission-and-vision/. Accessed March 8, 2015.

5. Webb DA, Bloch JR, Coyne JC, Chung EK, Bennett IM, Culhane JF. Postpartum physical symptoms in new mothers: their relationship to functional limitations and emotional well-being. Birth. 2008 Sep;35(3):179-87.