Peripartum Pelvic Floor Disorders Explained

[Dr. Lisa Hickman]
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.