Subspecialty care for peripartum pelvic floor disorders

Obstetric Anal Sphincter Injury: Interpregnancy Interval and Route of Subsequent Delivery

IMPORTANCE

Knowledge on the interpregnancy interval (IPI) among women with an obstetric anal sphincter injury (OASI) is both limited and not well understood.

OBJECTIVES

The objectives of this study were to describe the IPI among women with OASI and to compare women with OASI based on the route of subsequent obstetric delivery and OASI recurrence.

STUDY DESIGN

This was a retrospective single-cohort study of women who had an OASI between 2013 and 2015 at a tertiary academic medical center. Demographics, obstetric delivery data, postpartum sequelae, and subsequent pregnancy delivery data from 2013 to 2021 were collected. The IPI was defined as the time from date of first vaginal delivery to date of conception of the subsequent pregnancy. Women without a subsequent pregnancy were censored at the date of last contact. The IPI was evaluated using a survival analysis (Kaplan-Meier estimator).

RESULTS

A total of 287 women experienced an OASI, and subsequent pregnancy occurred for 178 (62.0%) women. The median IPI was 26.4 months (95% confidence interval: 23.7-29.9) for women with a prior OASI. Of the 97 women who did not have a subsequent pregnancy documented during the study, the median follow-up was 64.0 months (interquartile range: 5.7-80.0). Subsequent delivery route data were available for 171 women; of those, 127 (74.3%) experienced a subsequent vaginal delivery and 44 (25.7%) experienced a cesarean delivery. Of the 127 women who experienced a subsequent vaginal delivery, 3 (2.4%) experienced a recurrent OASI.

CONCLUSION

The IPI among women with OASI is similar to the IPI for all women in Ohio and in the United States.

Maintaining A Long-Term Practice of Daily Pelvic Floor Muscle Exercises: What Do Childbearing Women Think?

INTRODUCTION

To be effective, pelvic floor muscle therapy (PFMT) exercises should be intense, be practiced consistently, and include clinical support. Many women do not adhere to a consistent PFMT program, compromising the resolution or prevention of urinary incontinence (UI). This study aimed to answer 2 key questions: What prevents women from performing PFMT long term, and what can health care providers do to support women to perform them?

METHODS

Postpartum women from 4 sites in the United States completed a questionnaire about experiences with PFMT or Kegel exercises during and after pregnancy. This study focused on one of the 7 open-ended questions: What would prevent you from performing Kegels lifelong? Thematic analysis was implemented via an inductive approach using Braun and Clarke's 6-phase process.

RESULTS

Three salient themes emerged that help explain factors that prevent women from adhering to a daily PFMT routine: (1) life gets in the way, (2) inadequate PFMT education and instruction, and (3) disconnect exists about long-term consequences. The sample included 368 participants.

DISCUSSION

The themes were congruent with the limited body of qualitative literature on experience with PFMT exercises. This study was able to identify areas of need in the US maternal health care system to help childbearing people adopt daily PFMT, such as (1) inadequate parental leave and childcare support, (2) no formalized education related to UI and PFMT and a lack of pelvic health promotion, (3) lacking prioritization of long-term PFMT, and (4) the need to dispel the acceptance that UI postbirth is normal. Health care providers should prioritize interactive education, emphasizing how to correctly perform PFMT and the importance and effectiveness of integrating clinical support. To adequately encompass pelvic floor health care and education up to one year postbirth, changes are needed to the US perinatal health care system, providing sufficient insurance reimbursement and parental social support programs.

Repair of episiotomy and obstetrical perineal lacerations (first-fourth)

Perineal injury after vaginal delivery is common, affecting up to 90% of women. Perineal trauma is associated with both short- and long-term morbidity, including persistent pain, dyspareunia, pelvic floor disorders, and depression, and may negatively affect a new mother's ability to care for her newborn. The morbidity experienced after perineal injury is dependent on the type of laceration incurred, the technique and materials used for repair, and the skill and knowledge of the birth attendant. After all vaginal deliveries, a systematic evaluation including visual inspection and vaginal, perineal, and rectal exams is recommended to accurately diagnose perineal lacerations. Optimal management of perineal trauma after vaginal birth includes accurate diagnosis, appropriate technique and materials used for repair, providers experienced in perineal laceration repair, and close follow-up. In this article, we review the prevalence, classification, diagnosis, and evidence supporting different closure methods for first- through fourth-degree perineal lacerations and episiotomies. Recommended surgical techniques and materials for different perineal laceration repairs are provided. Finally, best practices for perioperative and postoperative care after advanced perineal trauma are reviewed.

Pelvic Floor Physical Therapy Attendance Among High-Risk Postpartum Patients

IMPORTANCE

Limited data describe attendance to pelvic floor physical therapy (PFPT) in a postpartum patient population.

OBJECTIVES

The objective was describe attendance to PFPT in a cohort of postpartum women at high-risk of pelvic floor concerns. We secondarily compared attendance between patients with and without evaluation in a postpartum pelvic floor healing clinic (PPFHC).

STUDY DESIGN

This was a retrospective cohort study of 2 convenience samples from an academic hospital. The PPFHC cohort comprised all postpartum vaginal delivery patients evaluated in the PPFHC from July 2021 to July 2022. The historical pre-PPFHC cohort comprised patients with third/fourth-degree obstetrical lacerations from December 2019 to January 2021. We abstracted attendance to PFPT, number of visits, Pelvic Floor Distress Inventory-20 (PFDI-20) scores, Pelvic Floor Impact Questionnaire (PFIQ) scores, and discharge status.

RESULTS

Our cohort contained 464 patients, 195 (42.0%) from pre-PPFHC and 269 (58.0%) from PPFHC. Among all patients 302 (65.1%) were referred to PFPT and 170 (56.3%) attended at least 1 visit, 82 (48.2%) were discharged from PFPT with goals met, and the median number of visits was 6 (3-10). The majority of patients (97.0%, n = 261) seen in the PPFHC were referred to PFPT, compared with 22.0% (n = 41) of pre-PPFHC patients (P < 0.01). More patients in the pre-PPFHC cohort attended PFPT than in those the PPFHC cohort (75.6% vs 53.5%, P ≤ 0.01). Most patients exhibited improved PFDI and PFIQ scores after PFPT (n = 88, 80.0%, and n = 89, 81.7% respectively).

CONCLUSIONS

Patients attending postpartum PFPT demonstrated high therapy completion rates. A dedicated PPFHC had more referrals, however, lower PFPT attendance rates, when compared with a historical cohort.

Pelvic floor injury during vaginal birth is life-altering and preventable: what can we do about it?

Pelvic floor disorders after childbirth have distressing lifelong consequences for women, requiring more than 300,000 women to have surgery annually. This represents approximately 10% of the 3 million women who give birth vaginally each year. Vaginal birth is the largest modifiable risk factor for prolapse, the pelvic floor disorder most strongly associated with birth, and is an important contributor to stress incontinence. These disorders require 10 times as many operations as anal sphincter injuries. Imaging shows that injuries of the levator ani muscle, perineal body, and membrane occur in up to 19% of primiparous women. During birth, the levator muscle and birth canal tissues must stretch to more than 3 times their original length; it is this overstretching that is responsible for the muscle tear visible on imaging rather than compression or neuropathy. The injury is present in 55% of women with prolapse later in life, with an odds ratio of 7.3, compared with women with normal support. In addition, levator damage can affect other aspects of hiatal closure, such as the perineal body and membrane. These injuries are associated with an enlarged urogenital hiatus, now known as antedate prolapse, and with prolapse surgery failure. Risk factors for levator injury are multifactorial and include forceps delivery, occiput posterior birth, older maternal age, long second stage of labor, and birthweight of >4000 g. Delivery with a vacuum device is associated with reduced levator damage. Other steps that might logically reduce injuries include manual rotation from occiput posterior to occiput anterior, slow gradual delivery, perineal massage or compresses, and early induction of labor, but these require study to document protection. In addition, teaching women to avoid pushing against a contracted levator muscle would likely decrease injury risk by decreasing tension on the vulnerable muscle origin. Providing care for women who have experienced difficult deliveries can be enhanced with early recognition, physical therapy, and attention to recovery. It is only right that women be made aware of these risks during pregnancy. Educating women on the long-term pelvic floor sequelae of childbirth should be performed antenatally so that they can be empowered to make informed decisions about management decisions during labor.

Perineal lacerations and social media: can patients find reliable information on Instagram and TikTok?

INTRODUCTION AND HYPOTHESIS

Social media content related to patient experiences and education continues to grow. Information on how obstetric perineal lacerations are represented on social media is limited. Our goal is to characterize available social media content on obstetric perineal lacerations.

METHODS

This is an IRB-exempt study using publicly available data on commonly searched topics about perineal lacerations to create a list of queries for Instagram and TikTok. The ten queries and "keyword" searches with the highest number of posts were identified from this list. The 50 most recent posts were reviewed for relevance, quality of content, and authorship. Topic-relevant posts were analyzed.

RESULTS

The search yielded 427 posts on Instagram and 500 on TikTok. Instagram yielded more topic-relevant posts than TikTok (94.1% vs 44.8%). Almost 50% of posts were categorized as educational. Instagram identified more patient experience-related posts (29.6%) whereas TikTok provided more humorous content (26.3%). Patients produced 27.6% of content on Instagram and 43.3% on TikTok. Physical therapists produced 18.9% of posts on Instagram and 21.9% on TikTok. They constituted the largest group of health professionals to post overall. Physician-created educational content accounted for 10.3% of posts on Instagram and 6.0% on TikTok.

CONCLUSIONS

Compared with TikTok, Instagram may be a more informative social media platform for educational or patient experience-related content. Given the paucity of physician-created content and given that only half of all posts are educational, providers should encourage social media engagement for community and networking purposes, while encouraging caution with regard to cosmetic products and advertisements.

Management of postpartum perineal wound complications

PURPOSE OF REVIEW

Perineal wound complications occur in up to 25% of postpartum patients. Wound complications are most common after obstetric anal sphincter injuries (OASIS) but can occur after any laceration. It is imperative that any provider caring for postpartum patients understand the best evidence-based practices to recognize and manage these complications. We present a review of the available literature on the management of postpartum perineal wound complications.

RECENT FINDINGS

There is a paucity of new publications on the management of postpartum perineal wound complications, despite an increased emphasis on postpartum recovery in women's health. The role of topical estrogen in healing of perineal wounds was investigated in a pilot study, demonstrating that granulation tissue does express estrogen receptors, and the use of estrogen increases cell proliferation. Progression of perineal wound healing by secondary intention was evaluated in an observational study. Wound healing was delayed in 30% of women, with the initial wound area, perimeter, bacterial colonization, and OASIS being associated with delayed healing.

SUMMARY

Evidence based practices on timing of follow-up, addressing wound care and analgesia, administrating antibiotics, timing secondary repair, and surgical technique all play a role in optimizing recovery and reducing morbidity in patients with postpartum perineal wound complications.

Opportunities to Advance Postpartum Pelvic Floor Care With a Health Equity-based Conceptual Framework

An essential part of postpartum care includes the evaluation and treatment of pelvic floor disorders (PFDs). Postpartum PFDs are common and occur in over 40% of postpartum women. Despite significant advancements in urogynecology to understand postpartum PFDs and their treatments, there has been a lack of attention to addressing equity in postpartum pelvic floor care. In this article, we address the current scientific understanding of postpartum PFDs while adapting a health equity-based conceptual framework to highlight areas of opportunity in optimizing postpartum pelvic floor care.

Starting a peripartum pelvic floor disorder clinic: what to expect in the first thirty-six months

INTRODUCTION AND HYPOTHESIS

Subspecialty peripartum pelvic floor disorder (PFD) clinics provide care to a unique patient population. We aim to describe the experiences of such a clinic in the first 36 months after its establishment.

METHODS

This is a descriptive case series of all women who presented to a subspecialty PFD clinic at an academic medical center over 36 months (January 2018-December 2020). Patient characteristics, referral patterns, and care plans will be described.

RESULTS

Four hundred eighty-three women presented for care. Women were a mean age of 31.0 ± 4.2 years, most were primiparous (404, 83.6%), and over half (279, 57.8%) had a spontaneous vaginal delivery. Three hundred eighteen women (66.9%) had obstetric anal sphincter injury (OASI), which was also the primary referral indication in 313 (64.8%). Most consultations were from an obstetrician (246, 51.3%), and the median time from delivery to evaluation was 17 days (IQR 11.0-34.0). The majority of women had one additional follow-up visit (330, 68.3%). One hundred forty-one (29.9%) women underwent minor office procedures, and 26 (5.4%) underwent surgery. The number of referrals sequentially increased from year 1 (59, 12.2%) to year 3 (215, 44.5%).

CONCLUSIONS

The 36-month experiences in our growing subspecialty peripartum PFD clinic demonstrate both sustainability and feasibility of this new service line, with consistent clinical growth over time and 483 new consultations, 2/3 of which were for OASI and the other 1/3 for a variety of peripartum pelvic floor indications. Our data outline a model for care, including timeline for follow-up, treatments administered, and number of interventions, both office and surgical.

Women’s knowledge about the physical therapist’s performance in women’s health

ABSTRACT This study aimed to evaluate the profile of knowledge of Brazilian women about the physical therapist’s role in women’s health. The women answered an online questionnaire containing: socioeconomic, demographic data, knowledge about the role of physical therapy in women’s health, and current health conditions. Descriptive analyses were carried out to characterize the sample, levels of knowledge and self-report of pelvic floor dysfunctions, and the association between general knowledge, self-report of dysfunctions, and knowledge of the sub-areas of physical therapy in women’s health. In total, 446 women from all regions of Brazil participated: 86.3% from the Southeast, 9.4% from the South, 1.6% from the Northeast, 1.3% from the Midwest, and 1.3% from the North. The mean age was 30.1±10.5 years; the self-report of pelvic floor dysfunctions was 20.4% urinary incontinence, 27.6% sexual dysfunctions, 25.8% intestinal symptoms, and 6.7% chronic pelvic pain. Of the participants, 61% had some knowledge about the role of physical therapy in women’s health and 96.9% would like to know more about this specialty. Although many women are aware of this area, a minority has been referred to or has undergone specialized physical therapy treatment for women’s health. There was a statistically significant association between the level of knowledge of women about the physical therapist’s role in women’s health with the self-report of pelvic floor dysfunctions and the level of knowledge of the sub-areas of performance.

Perfil do conhecimento de mulheres sobre a atuação do fisioterapeuta na saúde da mulher

RESUMO Objetivou-se avaliar o perfil do conhecimento de mulheres brasileiras sobre a atuação do fisioterapeuta na saúde da mulher. As participantes preencheram um questionário online contendo: dados socioeconômicos e demográficos, questões acerca do conhecimento sobre a atuação da Fisioterapia na Saúde da Mulher e das atuais condições de saúde. Foram realizadas análises descritivas para a caracterização da amostra, os níveis de conhecimento e o autorrelato de disfunções do assoalho pélvico e para a associação entre o conhecimento geral, o autorrelato de disfunções e o conhecimento das subáreas da Fisioterapia na Saúde da Mulher. Participaram 446 mulheres de todas as regiões do Brasil, sendo 86,3% do Sudeste, 9,4% do Sul, 1,6% do Nordeste, 1,3% do Centro-Oeste e 1,3% do Norte. A média de idade foi de 30,1±10,5 anos. O autorrelato de disfunções do assoalho pélvico foi de 20,4% de incontinência urinária, 27,6% de disfunções sexuais, 25,8% sintomas intestinais e 6,7% de dor pélvica crônica. Das participantes, 61% apresentavam algum conhecimento sobre a área da Fisioterapia na Saúde da Mulher e 96,9% gostariam de conhecer mais sobre essa especialidade. Apesar de muitas mulheres terem conhecimento sobre essa área, uma minoria já foi encaminhada ou realizou tratamento especializado de Fisioterapia na Saúde da Mulher. Houve associação estatisticamente significativa entre o nível de conhecimento das mulheres sobre a atuação do fisioterapeuta na saúde da mulher com o autorrelato de disfunções do assoalho pélvico e o nível de conhecimento das subáreas de atuação.

Three-year follow-up of a self-administered Australian pelvic floor questionnaire validated in Chinese pregnant and postpartum women

INTRODUCTION AND HYPOTHESIS

The aim of this study was to verify whether the Chinese version of the self-administered Australian Pelvic Floor Questionnaire (APFQ) can assess the changes in symptoms over a long time period (responsiveness) and to verify the reliability and validity of the questionnaire after 3 years of follow-up.

METHODS

The questionnaire was completed by 146 women using the WeChat platform after 3 years of follow-up. Reliability was assessed through internal consistency (Cronbach's alpha). Construct validity was evaluated by significantly distinguished differences in symptom scores between women who did and did not subjectively suffer bothersome symptoms. Responsiveness was evaluated in 146 women. The effect size (ES) and standardized response mean (SRM) were used to assess the degree of responsiveness.

RESULTS

Of the 146 women, all completed the questionnaire through the WeChat platform without missing any items. Reliability, Cronbach's alpha for the four domains and total APFQ were: bladder function 0.78, bowel function 0.71, pelvic organ prolapse 0.78, sexual function 0.68 and total APFQ 0.84. Concerning construct validity, the APFQ significantly distinguished the symptom scores between women who did and did not subjectively suffer from bothersome symptoms, and the score difference was 1.1-1.6 points, 1.2 points, 2.0-3.7 points and 1.4 points, respectively. For responsiveness, three domains showed slight (bowel domain) to moderate (bladder domain, sex domain) sensitivity to change. ES and SRM ranged from 0.21 to 0.75 and 0.16 to 0.60, respectively.

CONCLUSIONS

The Chinese version of the self-administered APFQ is reliable and valid and can monitor the changes in symptoms over time.

Predictors for sexual dysfunction in the first year postpartum: a systematic review and meta-analysis

BACKGROUND

Pregnancy and childbirth increase the risk for pelvic floor dysfunction, including sexual dysfunction. So far, the mechanisms and the extent to which certain risk factors play a role remain unclear.

OBJECTIVES

In this systematic review of the literature we aimed to determine risk factors for sexual dysfunction in the first year after childbirth.

SEARCH STRATEGY

We searched MEDLINE, Embase and CENTRAL using the search strategy: sexual dysfunction AND obstetric events.

SELECTION CRITERIA

We included original, comparative studies, reported in English, that used validated questionnaires and the ICS/IUGA terminology for sexual dysfunction, dyspareunia and vaginal dryness.

DATA COLLECTION AND ANALYSIS

We assessed the quality and the risk of bias of the included studies with the Newcastle-Ottawa scale. We extracted the reported data and we performed random-effects meta-analysis to obtain the summary odds ratios (ORs) with 95% confidence intervals (95% CIs). Heterogeneity across studies was assessed using the I² statistic.

MAIN RESULTS

Anal sphincter injury was associated with increased odds for both sexual dysfunction (OR 3.00, 95%CI 1.28-7.03) and dyspareunia (OR 1.92, 95% CI 1.47-2.52). Episiotomy was associated with dyspareunia (OR 1.64, 95% CI 1.25-2.14), but not with sexual dysfunction (OR 1.90, 95% CI 0.94-3.84). Compared with spontaneous birth, caesarean section reduced the odds for dyspareunia (OR 0.68, 95% CI 0.54-0.86) but not for sexual dysfunction (OR 1.14, 95% CI 0.89-1.46). Instrumental vaginal birth increased the odds for sexual dysfunction (OR 1.70, 95% CI 1.05-2.76), yet no difference was found for dyspareunia (OR 1.82, 95% CI 0.88-3.75). One study of low quality reported on vaginal dryness and found no association with obstetric events.

CONCLUSIONS

Perineal trauma, rather than mode of birth, increases the odds for sexual dysfunction in the first year after childbirth.

TWEETABLE ABSTRACT

Perineal trauma, rather than mode of birth, correlates with sexual dysfunction and dyspareunia postpartum. #dyspareunia #OASI #episiotomy.

Recognition and Management of Pelvic Floor Disorders in Pregnancy and the Postpartum Period

Often considered a condition of aging women, pelvic floor disorders may initially present in pregnancy and postpartum, having a negative impact on quality of life during this important time in a woman's life. This review outlines the clinical approach to implementing pelvic health into obstetric care through education and promotion of pelvic health in pregnancy, screening for pelvic floor disorders routinely, and providing support through resources, treatment, and referrals if pelvic floor disorders develop during pregnancy and postpartum.