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BackTable / OBGYN / Article
Peripartum Pelvic Floor Disorders: A Multidisciplinary Approach
Sophie Frankenthal • Updated Nov 17, 2024 • 31 hits
The peripartum period, which includes pregnancy, childbirth, and the immediate postpartum phase, is typically a time of focused OB-GYN care. However, a significant gap exists in the continuity of care during this time, particularly in managing peripartum pelvic floor disorders. While immediate care during pregnancy and delivery is prioritized, many women experience inadequate follow-up postpartum, leaving pelvic floor disorders and related complications unaddressed. This lack of postpartum care can lead to a range of long-term consequences, such as urinary incontinence, dyspareunia, and other debilitating conditions that can severely impact a woman’s quality of life. Addressing this gap is critical for improving long-term maternal health.
Dr. Lisa Hickman, in collaboration with her colleagues at the Cleveland Clinic, founded a postpartum follow-up clinic. Drawing on this experience, she emphasizes the importance of early intervention and comprehensive care models that extend beyond the immediate postpartum period, ensuring lasting recovery and optimal pelvic health.
This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable OBGYN Brief
• The pelvic floor is a collection of muscles that support the pelvic organs. These muscles are particularly susceptible to damage during pregnancy and childbirth, resulting in a variety of peripartum pelvic floor disorders.
• Peripartum pelvic floor disorders include both immediate structural injuries such as severe perineal laceration, and long-term complications such as dyspareunia, rectovagina fistulas, and urinary or fecal incontinence.
• Effective care for peripartum pelvic floor disorders requires a multidisciplinary approach, integrating medical management, pelvic floor physical therapy, and mental health support as needed.
• Establishing a postpartum pelvic floor clinic requires coordinated planning, proactive stakeholder engagement, and a streamlined referral system to provide timely care and to support sustained pelvic health recovery.
Table of Contents
(1) Defining Peripartum Pelvic Floor Disorders
(2) A Comprehensive Model for Postpartum Care
(3) Practical Tips for Opening a Postpartum Clinic
Defining Peripartum Pelvic Floor Disorders
The pelvic floor is a network of muscles, including the levator ani, which supports the pelvic organs. These muscles are particularly vulnerable to injury during pregnancy and childbirth. Injuries to these muscles, collectively referred to as “peripartum pelvic floor disorders,” encompass a wide range of muscle damage and functional impairments stemming from the physiological changes that occur during this period.
During pregnancy, significant hormonal shifts naturally increase the laxity within the pelvic floor, causing many women to experience urinary symptoms such as urgency or incontinence as early as the first trimester. Childbirth, particularly vaginal delivery, results in further stretching of the pelvic floor muscles, sometimes by over 200%. This can lead to lasting injuries including levator ani avulsions and pudendal nerve damage. Additionally, approximately 80% of deliveries involve perineal lacerations of varying severity, which further contributes to postpartum pelvic floor complications. The staggering likelihood of postpartum injury highlights the need for proactive identification and management of peripartum pelvic floor disorders.
[Dr. Amy Park]
…Can you just share some of your insights on what are the sequelae of pregnancy and childbirth and how does it affect the pelvic floor? What is the pelvic floor? Just really basic questions.
[Dr. Lisa Hickman]
All right. Let's start with the foundation here, which is the pelvic floor. The pelvic floor is a bowl of muscles. The levator ani are the buzz muscles that people typically know. They are a bowl of muscles that attach to the bony pelvis and support the pelvic organs. When they are not functioning like they're supposed to, we get pelvic floor disorders. I think that this area, peripartum pelvic floor disorders, advanced obstetric lacerations, has a really natural leaning to urogynecology.
Really, during pregnancy, it's the first time that women even think about their pelvic floor. 80% of women will have frequency and urgency pretty early in pregnancy. Lots of women have urinary incontinence for the first time, so it really makes sense that we should have an influence in this area.
[Dr. Amy Park]
I was just going to say, what does pregnancy even do to the pelvic floor?
[Dr. Lisa Hickman]
I think that's a complicated question. We know, obviously, changes in the hormonal milieu affect pelvic support. There are studies looking at nulliparous patients throughout pregnancy. There is naturally increasing laxity in the pelvic support and even some low-grade pelvic organ prolapse. The changes in the hormonal milieu that relax the muscles can also affect continence. All of those things together can contribute to some mild pelvic floor disorders during pregnancy. Most of the time, I think patients just assume it's a natural part of pregnancy, and it is, but it's still pelvic floor symptoms.
[Dr. Amy Park]
Then how does childbirth affect the pelvic floor?
[Dr. Lisa Hickman]
That's a great question. Childbirth in and of itself, there have been some actually really great modeling studies out at the University of Michigan with Dr. Deliancy looking at the stretch of the levator ani muscles during delivery. They stretch over 200%, the medial levator ani muscles. That stretch increases as the fetal head diameter increases. There are stretch injuries of the pelvic floor. There have been studies looking at nulliparous patients compared to primiparous patients. Up to a third of patients can have levator ani avulsion on imaging studies. Then there's also nerve injury. We know that the branches of the pudendal nerve can have stretch injury during delivery.
The stretch to those branches exceeds what we have seen in animal models that can because permanent damage to the nerves. There is real impact on the pelvic floor and its innervation during a vaginal delivery. We know that up to 80% will experience a laceration at the time of their delivery. There's direct injury to the pelvic floor muscles, specifically, most commonly, those that convene at the perineal body. One area that has been a real interest of mine is advanced obstetric lacerations, third and fourth-degree tears. We know that there can be some pretty significant sequelae that happen postpartum from those tears.
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A Comprehensive Model for Postpartum Care
The postpartum care clinic model, developed at the Cleveland Clinic by Dr. Lisa Hickman and her colleagues, emphasizes early follow-up for patients experiencing peripartum pelvic floor disorders, particularly for those with third- and fourth-degree perineal tears. The model emphasizes timely follow-up to manage a high incidence of complications, including wound infection (20%), wound breakdown (25%), and fecal urgency (up to 30%).
Severe tears can lead to significant physiological and psychological challenges, from chronic pain and dyspareunia (painful intercourse) to more complex sequelae like rectovaginal fistulas and anal incontinence. To address these, the clinic provides a comprehensive, interdisciplinary approach, incorporating wound care, bowel regimens, pelvic floor physical therapy, and mental health screenings with referrals as needed.
Patient education is another core component of the peripartum clinic model, covering the causes and implications of injuries to empower patients with informed decisions about future deliveries. This supportive model not only mitigates long-term physical and emotional impacts, but also reinforces patients’ confidence in managing their postpartum recovery and health.
[Dr. Amy Park]
What kind of things are you feeling or are you seeing in your clinic? I just remember when I first got here in 2020, you and Katie Probst had-- It was your passion. You worked with her to stand up this clinic. In addition to the things that you're treating, you were obviously addressing and closing a gap, but also, what were some of your insights into standing up a clinic both here and at Ohio State? I know there's a lot of questions there, but I’m just curious because there's a lot of stuff that you have to address.
[Dr. Lisa Hickman]
Those are great questions. The model of the clinic that I started at the Cleveland Clinic, which is the postpartum care clinic. It still exists today, is that we would see all patients who had third and fourth-degree tears during delivery at a short interval, which is really in line with what ACOG has recommended that women need postpartum care at a shorter interval, whether that's a touch base, an appointment with a midwife, or an APP.
We wanted to see these patients early postpartum because we know that there's a high incidence of wound complications. Wound infection can happen in about 20% of patients who have third and fourth-degree tears. Wound breakdown up to 25% of patients. Then acute pain is a pretty significant issue for these patients short term. Some patients do transition into some long-term chronic pain after these tears.
Other things, postpartum, we know for this patient population, there's a high rate of fecal urgency up to 30% of patients, but it's probably honestly even more than that from what I anecdotally see in clinic from talking to patients. Anal incontinence can be as high as 60%. Incontinence of flatus or stool, and that is a sequelae I think that psychologically really affects women because they really only ever imagine that one person in their household would be in diapers after they have a baby and that it wasn't them. Rectovaginal fistulas is an incidence of 1% to 2% in this patient population.
If enough of these patients, you will for sure be taking care of complex fistulas. I actually just took care of a woman who had her second baby, second-degree tear with her first. She had a breakdown of the perineum that connected to the rectum. It was a recto-perineal fistula. It was totally unanticipated, especially given that she had a second-degree tear in her last pregnancy. More than the incontinence, more than the prolapse. Dyspareunia can be a big issue in this patient population.
Then the psychological impact and the PTSD that can come from a traumatic delivery. talking to patients, I have patients who say like, "There is no way I can have another vaginal delivery. I already decided we need to adopt because if someone is going to make me have another delivery vaginally in the future, I just can't do it." I think it's really important to create a space. These visits are a lot of education.
When then early postpartum, there's a lot to unpack, but we make sure that they're on a bowel regimen. We address pain control issues. We are screening them with the Edinburgh Postnatal Depression Scale to evaluate for any early postpartum depression and anxiety. Then it's a lot of education of what happened and why did it happen, what was involved, and what does it mean for the future.
[Dr. Amy Park]
That is a lot of stuff. I was just going to say-
[Dr. Lisa Hickman]
It's a lot.
…
[Dr. Amy Park]
-do you have a social worker who works alongside you in pelvic floor PT or you just refer to them or how does that work?
[Dr. Lisa Hickman]
I would love to have a social worker. I think that there's a lot that we could do there, but unfortunately, we don't. I get creative with my resources. We have great teams of people that I can refer out to for depression, anxiety, things like that. We work closely with lactation if patients are struggling there. Then we actually do have an incredible pelvic floor PT department at Ohio State. We set up tandem appointments for patients. They see me, and then they're able to go see physical therapy the same day. Even if they're not ready for full-blown pelvic floor PT, the physical therapist and I and many other experts in this area feel like early intervention is where it's at.
…
[Dr. Lisa Hickman]
I do think that that's a really interesting point you make, Amy, about the role of physical therapy after obstetric delivery, and that's something that I've been also super interested in. Obviously, pelvic floor physical therapy is a limited resource, and getting every woman in for PT would, I think, overwhelm at least our system at Ohio State. One program that I started at Ohio State, which is now actually up and running, is called S.M.A.R.T Start to Motherhood. I got a grant.
Basically, S.M.A.R.T Start stands for Supplying Medical knowledge And Rehabilitative Therapy. We made high-impact patient education videos that everyone who is enrolled at Ohio State has access to during their pregnancy. They get access to them in the third trimester. It's all topics that women tell me they wish they would have known. Bowel and bladder control issues in pregnancy and postpartum, sexual dysfunction postpartum, sexual pain and changes in desire, postpartum mood disorders, the pelvic floor and what it is, obstetric lacerations, things like that.
Then as part of the program, we have group pelvic floor PT classes that anyone who has a delivery at OSU has access to go to. At least, you get in a group setting and can learn some basics of how to use your pelvic floor and contract your pelvic floor. If you really feel like you need more than that, then you talk to your obstetric provider, and you can see about getting a referral to go back and do one-on-one therapy.
Practical Tips for Opening a Postpartum Clinic
Establishing a dedicated postpartum pelvic floor clinic requires structured planning, coordinated collaboration, and robust clinical infrastructure. Dr. Lisa HIckman shares her experience in building such a model, emphasizing the importance of proactively engaging stakeholders – including obstetric teams – through clear communication of the clinic’s mission and goals.
A key component of the clinic’s success is an efficient patient identification and referral system, including best practice alerts embedded in the EMR, which prompts referrals for patients presenting with third- or fourth- degree tears, complex wound-healing, or any other peripartum pelvic floor disorder. The clinic employs a nurse navigator who triages patients based on acuity, as well as advanced practice providers (APP) for management of lower-acuity cases, both of which enable the effective allocation of resources. By streamlining referrals and providing structured support, the clinic addresses immediate postpartum needs while simultaneously anticipating long-term pelvic health outcomes. This proactive model bridges gaps in postpartum care, delivering timely interventions and education during the critical “fourth trimester” to support sustained recovery following childbirth.
[Dr. Mark Hoffman]
Can you talk about building that clinic, though? I think there's things that make it challenging, obviously having a urogynecologist who-- or at least somebody who is interested, aware, educated in this postpartum, peripartum complications. Just a billing question, does this fall under the global billing period for obstetrics and is this a special separate issue that you can bill separately for as a consult? When someone's building a clinic like this, what are the things they need to think about or know about?
[Dr. Lisa Hickman]
Yes, those are good questions. I actually had the pleasure of writing a paper on starting a peripartum clinic that you can find in the gray journal. It was a collaboration with Katie Probst, Carolyn Swenson, who's now at the University of Utah, and Christina Lewicky-Gaupp. We knew that this is an emerging area that people have had growing interest in. We wanted to have a roadmap that people could reference on here's what you need to know to start a clinic.
I think the first thing is a lot of planning and understanding who the stakeholders are. When I was designing this clinic, I felt like I went on a PR tour. I gave grand rounds at both hospitals that we did deliveries at Cleveland Clinic. I wanted to make it very clear that this is a team approach, that I am not Monday morning quarterbacking what is done in the labor room. In fact, I am the biggest advocate for obstetricians. I think that they have an incredibly challenging job when they do these repairs on tissue that is incredibly edematous.
They are working in not the most ideal lighting or not the most ideal instruments, and they have 20 other people on the labor board at the same time who need their attention. I think just making it very clear what the mission is and how you are going to work in tandem with them is really important because you will really get allies. This totally became a field of dream situation. I built it and they came.
I think a big infrastructural thing that made a huge difference is that we created a best practice alert in the EMR so that anytime a third or fourth-degree repair was marked in the delivery record, it prompted like, "Would you like to refer to this clinic?" Then we also created an infrastructure, so patients could also be referred if they had complex wound breakdown, if they wanted to be seen antepartum for prolapse or urinary incontinence, or if they wanted to be seen postpartum for some other pelvic floor issue, there was a freestanding order. We do bill these as new consults, and I have not received word from my billing colleagues that it hasn't been paid out like that. That's the model that we've taken.
Then I think that there's a lot of low acuity for many of these patients. There are lots of patients who have tears that heal beautifully. Once they get past the initial period, don't have any pelvic floor complaints. Those are great patients that you could team up with an APP, who you train, and that's exactly what we did at Cleveland Clinic. Abby Anderson was amazing, and she still is seeing these patients. In the beginning, she would just come see patients with me, got the hang of it, learn the counseling because a lot of it, like I said, is education. You really could team up with an APP, and it's a great service for patients.
[Dr. Amy Park]
It's a huge service, and there's such a gap. The other thing I will say on the back end that I know is a big deal is getting a nurse navigator. Now, I don't know how many urogyn clinics can have a nurse navigator. Now we have two actually, and it really helped to triage these patients. The other thing is it's the initial referrals got-- Our nurse navigators used to take care of it, but now there's somebody who actually screens all postpartum. I can't remember exactly what boosts these patients up into her sphere, but she is helping with triaging because there's just such a huge need.
Then she will triage the low acuity from the higher acuity because routine postpartum hemorrhoids or sexual dysfunction can go to pelvic floor PT without needing urogyn. You know what I mean. Some vaginal oestrogen but then a lot of other people need a little bit more care. A lot of people just need some PT, period. I see a lot of stress incontinence in that clinic too. I see a couple of those patients. Honestly, I don't know the percentages, but a lot of people have postpartum stress incontinence, and it goes away in the first year. It's 60% or something, right?
[Dr. Lisa Hickman]
It is very high. That's another good point is we know the natural history of many of these pelvic floor issues postpartum and for most of them by three months postpartum. If you can get patients past that fourth trimester, it will be significantly improved. Some of the other studies that follow women out, there might be interval improvement between three and six months postpartum, but truly, once you get to about six months postpartum, probably, what you have is what it's going to be.
Podcast Contributors
Dr. Lisa Hickman
Dr. Lisa Hickman is a gynecologic surgeon at Ohio State College of Medicine in Columbus, Ohio.
Dr. Mark Hoffman
Dr. Mark Hoffman is a minimally invasive gynecologic surgeon at the University of Kentucky.
Dr. Amy Park
Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.
Cite This Podcast
BackTable, LLC (Producer). (2024, October 1). Ep. 66 – Peripartum Pelvic Floor Disorders Explained [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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