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Pelvic Floor Risk Ass 12/10/05 3 34 pm Page 1 PromoCon Pelvic Floor Risk Assessment Tool Surname. Forename. This will serve to give guidance in future management. Comments Please refer to continence service at - SUPPORTED BY AN EDUCATIONAL GRANT FROM NEEN HEALTHCARE This Risk Assessment Tool is the property of PromoCon and should not be altered without permission 10/05. Address. D. O. B. Consultant. Hospital Number. Part 1 Antenatal Assessment To be completed at booking Date of Assessment. Professional Signature. Print Name. Tick Previous history of bladder and bowel problems including bedwetting Age 35 Body Mass Index 30 Chronic constipation - needing to strain or use laxatives Multiparity Antenatal Score Total ACTION Currently incontinent- refer to continence service. If previous history of bladder and bowel problems discuss delivery options. If score 3 make a note in antenatal records that PELVIC FLOOR IS AT RISK and review management options. Part 2 Postnatal Assessment Date of Postnatal Assessment. Large baby 4kg Prolonged active second stage 1hr Forceps/ventouse delivery Perineal trauma other than first degree tear Epidural in labour Single Drainage by catheter 800mls Postnatal score total CURRENTLY INCONTINENT - REFER TO CONTINENCE SERVICE* 0 - Low Risk One to one PFME preferable plus literature 1 - 4 Medium Risk One to one PFME essential plus literature to indicate that patient is at risk 5 - 7 High Risk REFERRAL TO CONTINENCE SERVICE Part 3 Total score and supporting information to be passed on to the health visitor. Address. D. O. B. Consultant. Hospital Number. Part 1 Antenatal Assessment To be completed at booking Date of Assessment. Professional Signature. Print Name. Tick Previous history of bladder and bowel problems including bedwetting Age 35 Body Mass Index 30 Chronic constipation - needing to strain or use laxatives Multiparity Antenatal Score Total ACTION Currently incontinent- refer to continence service. Professional Signature. Print Name. Tick Previous history of bladder and bowel problems including bedwetting Age 35 Body Mass Index 30 Chronic constipation - needing to strain or use laxatives Multiparity Antenatal Score Total ACTION Currently incontinent- refer to continence service. If previous history of bladder and bowel problems discuss delivery options. If score 3 make a note in antenatal records that PELVIC FLOOR IS AT RISK and review management options. If previous history of bladder and bowel problems discuss delivery options. If score 3 make a note in antenatal records that PELVIC FLOOR IS AT RISK and review management options. Part 2 Postnatal Assessment Date of Postnatal Assessment. Large baby 4kg Prolonged active second stage 1hr Forceps/ventouse delivery Perineal trauma other than first degree tear Epidural in labour Single Drainage by catheter 800mls Postnatal score total CURRENTLY INCONTINENT - REFER TO CONTINENCE SERVICE* 0 - Low Risk One to one PFME preferable plus literature 1 - 4 Medium Risk One to one PFME essential plus literature to indicate that patient is at risk 5 - 7 High Risk REFERRAL TO CONTINENCE SERVICE Part 3 Total score and supporting information to be passed on to the health visitor.

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