Specialist infertility practice was studied in a group of 708 couples within a population of residents of a single health district in England. They represented an annual incidence of 1*2 couples for every 1000 of the population. At

Objectives To assess the effect of nurse assessment with reinforcement of pelvic floor muscle training exercises and bladder training compared with standard management among women with persistent incontinence three months postnatally. Design Randomised controlled trial with nine months' follow up. Setting Community intervention in three centres (Dunedin, New Zealand; Birmingham; Aberdeen). Participants 747 women with urinary incontinence three months postnatally, allocated at random to intervention (371) or control (376) groups. Intervention Assessment by nurses of urinary incontinence with conservative advice on pelvic floor exercises at five, seven, and nine months after delivery supplemented with bladder training if appropriate at seven and nine months. Main outcome measures Primary: persistence and severity of urinary incontinence 12 months after delivery. Secondary: performance of pelvic floor exercises, change in coexisting faecal incontinence, wellbeing, anxiety, and depression. Results Women in the intervention group had significantly less urinary incontinence: 167/279 (59.9%) v 169/245 (69.0%), difference 9.1% (95% confidence interval 1.0% to 17.3%, P = 0.037) for any incontinence and 55/279 (19.7%) v 78/245 (31.8%), difference 12.1% (4.7% to 19.6%, P = 0.002) for severe incontinence. Faecal incontinence was also less common: 12/273 (4.4%) v 25/237 (10.5%), difference 6.1% (1.6% to 10.8%, P = 0.012). At 12 months women in the intervention group were more likely to be performing pelvic floor exercises (218/278 (79%) v 118/244 (48%), P < 0.001). Conclusions A third of women may have some urinary incontinence three months after childbirth. Conservative management provided by nurses seems to reduce the likelihood of urinary and coexisting faecal incontinence persisting 12 months postpartum. Further trials for faecal incontinence are needed.

Objective To describe the prevalence and causes of postnatal maternal morbidity. Design Questionnaire survey of postnatal patients. Further data extracted from SMRl returns, case records and the Aberdeen Maternity and Neonatal Databank. Setting Postnatal care in a teaching maternity hospital, midwife delivery hospital, general practitioner maternity units and in the community. Subjects Twenty percent random sample of deliveries (1249 women) surveyed one week, eight weeks and 12 to 18 months after delivery. Main outcome measures Incidence of self reported maternal morbidity, treatment received, readmission rates and causes for readmission. Results Of mothers in the sample 85% (99% CI 82‐88%) reported at least one health problem in hospital, rising to 87% (84‐90%) of those at home; 76% (71‐81%) reported at least one health problem after eight weeks post‐delivery. Conclusions Maternal morbiditv is extensive and under‐recognised after delivery. Measures to reduce and alleviate it must be sought.

Objective To describe the sexual behaviour of postnatal women, including time of restarting intercourse, problems encountered, use of contraception and related use of available services.Design Longitudinal survey using postal questionnaires following discharge from hospital, and at eight weeks and twelve to eighteen months postnatally. SettingThe questionnaires referred to postnatal care received in a teaching hospital and general practitioner delivery units, and in the community.Population Randomly selected one in five sample of women who were delivered in the Crampian Region of Scotland over a 12-month period.Main outcome measures Times to restarting intercourse and contraception; problems related to intercourse and their relation to perineal pain, tiredness and method of infant feeding; and perceived need for and adequacy of help. ResultsThe median times to restarting intercourse and contraception were each six weeks. Problems with intercourse were reported by 569/1075 (53%, 95% CI 50-56) of women in the first eight weeks after delivery, and by 2151435 (49%, 95% CI 45-54) in the subsequent year. Women who reported perineal pain, depression or tiredness experienced problems related to intercourse more often than those who did not. Women who breastfed their infants were significantly less interested in intercourse than those who bottlefed, irrespective of tiredness or depression, but this effect did not persist in the long term. The need for help with problems was expressed by 7% to 13% of women, but a quarter of these had not sought it.Conclusions Postnatal sexual problems are common. Health professionals ought to educate and prepare patients antenatally; be trained to identify problems; and be competent to deal with them openly and sympathetically.

Trusted evidence. Informed decisions. Better health.

Abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse and dyspareunia than with vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair reduces the risk of recurrent anterior wall prolapse, on examination. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The value of the addition of a continence procedure to a prolapse repair operation in women who are dry before operation remains to be assessed. Adequately powered randomised controlled clinical trials are urgently needed on a wide variety of issues and particularly need to include women's perceptions of prolapse symptoms.

UK National Institute of Health Research.

The inclusion of new randomised controlled trials showed that the use of mesh at the time of anterior vaginal wall repair reduced the risk of recurrent anterior vaginal wall prolapse on examination. However, this was not translated into improved functional or quality of life outcomes. The value of a continence procedure in addition to a prolapse operation in women who are continent pre-operatively remains uncertain. Adequately powered randomised controlled trials are needed and should particularly include women's perceptions of prolapse symptoms and functional outcome.