Midwife training reducing women suffering with their pelvic floor

Devon midwives and pelvic health physiotherapists are witnessing first-hand the impact of teaching preventative pelvic floor education in antenatal care, where previously it wasn’t routinely provided – or understood.  

Lizzie Phillips, Pelvic Health Midwife, Stephanie Armitage and Naomi Reeves, perinatal Pelvic Health Physiotherapists, at University Hospitals Plymouth NHS Trust (UHP), have observed how an innovative education programme is reducing the number of women quietly suffering with their pelvic floor.

APPEAL (Antenatal Preventative Pelvic Floor Exercises And Localisation) is a programme of training and resources for maternity staff and pregnant people to understand the importance of pelvic floor health in pregnancy, and to teach and practice pelvic floor muscle exercises so they are less likely to leak urine before and after giving birth. This education can hold the key to a better quality of life for all women, preventing and treating common problems like urinary incontinence. 

This year Health Innovation South West has been working with researchers at the University of Exeter to support uptake and implementation of APPEAL.

Over 200 perinatal pelvic health and maternity service leads in England have been trained in APPEAL, including Lizzie, Stephanie and Naomi, who work in the Devon Perinatal Health Service at UHP.

Lizzie has observed the benefits of teaching preventative pelvic floor education to pregnant people.  

“Women know they’re meant to be doing pelvic floor exercises, as midwives we know we’re meant to be telling people to do them. But there was a gap in knowledge. How do I do them? How often do I do them? Why am I doing them? APPEAL has filled the gap”, explains Lizzie.

Using funding from NHS England, the Devon Perinatal Pelvic Health Service introduced APPEAL training for midwives in 2024.  

“[The service ] recognised there was a shortfall of women being able to access simple support for pelvic health problems, which will hugely impact their lives when they’ve just had a baby. As midwives we want to reduce the chances of these problems happening. If there’s something we can do, we’re on board” explains Lizzie.

“The first four training sessions were run as face-to-face sessions”, explain Stephanie and Naomi . “But due to time restraints and accessibility, we decided to trial the training programme online and haven’t looked back.”

Among the APPEAL resources for pregnant people are a suite of videos for midwives and pregnant women, produced by the University of Exeter and WILD and funded by Health Innovation South  Perinatal Pelvic Health Service is showing these videos on its website, maternity social media, and TVs in maternity clinic waiting rooms, as well as encouraging its maternity staff to discuss them with families.

UHP has also embedded the videos in a Real Birth Company e-learning package that it provides to expectant women during pregnancy.

“Questions are answered in a three-minute video from Leann. It’s accessible. It’s useful. It’s translatable”, enthuses Lizzie. 

The team at UHP has also extended the reach of APPEAL training beyond midwifery staff to the vaccination team, comprising of health visitors and community nurses.

“The vaccine team make contact with 50% of the pregnant population, which is a significant number, and they have more time with women while they talk about vaccinations”, says Lizzie. “They were teaching women about pelvic floors but had never had formal training on how to teach it. We realised they were teaching a technique different to APPEAL, and we wanted to align everyone by offering them the training.”

Lizzie, Stephanie and colleagues have completed what’s known as the APPEAL ‘Train the trainer’ course, where midwives and maternity staff are taught how to teach other staff to deliver pelvic floor education to women and families. For the Devon Perinatal Pelvic Health Service team, the act of delivering this training, in addition to the content itself, has been beneficial.  

“Presenting the research is really helpful. I have increased my knowledge significantly,” says Lizzie.

At UHP, APPEAL now complements the trust’s existing approach to birth preparation, including other preventative antenatal education on reducing the risk of obstetric anal sphincter injuries.

To Lizzie and Stephanie, the impact is noticeable. “We’re reducing the number of women suffering long term quietly”, Lizzie says.

“When I rang an antenatal patient who had been referred for antenatal urinary incontinence, by the time of her first appointment she had been doing the exercises prescribed by her midwife and was now not leaking urine”, reports Stephanie. “She reported feeling well supported and advised, and I was able to discharge her with advice that she could always re-refer if required, but this has not needed to happen.”

Trained maternity staff are positive about receiving pelvic health training that includes APPEAL too. “The feedback is outstanding”, reports Lizzie. “We have people saying this is the best training they have ever done. How they couldn’t believe they’ve been a midwife for 30 years and thought they knew everything there was to know, but there was so much more.”

Added Stephanie: “We have had great attendance and some interesting discussions within sessions. As a busy clinician, being provided with an evidence-based training package from the APPEAL team has helped to easily implement it into our monthly schedules.”

If adopted across the UK, pelvic floor education could transform outcomes for tens of thousands of pregnant women every year. Learn more about APPEAL.