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BackTable / OBGYN / Podcast / Transcript #66
Podcast Transcript: Peripartum Pelvic Floor Disorders Explained
with Dr. Lisa Hickman
Pregnancy and childbirth have a significant impact on the pelvic floor, often more than patients realize and even more still than most of our current postpartum care models are designed to address. In this episode of the BackTable OBGYN podcast, hosts Dr. Mark Hoffman and Dr. Amy Park welcome Dr. Lisa Hickman, a urogynecologist and pelvic reconstructive surgeon from The Ohio State University, to discuss peripartum pelvic floor disorders and her dedicated clinic for women with advanced obstetric lacerations. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Pregnancy, Childbirth, & the Pelvic Floor
(2) Perineal Tears: Risk Factors & Prevention
(3) C-Section vs. VBAC: Balancing Risk & Patient Preference
(4) Common Challenges in Postpartum Care
(5) Mental Health Support for the Peripartum Patient
(6) Opening a Peripartum Clinic: Key Considerations
(7) Expanding Access to Pelvic Floor Physical Therapy
(8) Advanced Tear Repair Best Practices
(9) Effective Training for Advanced Tear Repair
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[Dr. Mark Hoffman]
Hello, everyone, and welcome to The BackTable OBGYN Podcast, your source for all things obstetrics and gynecology. You can find all previous episodes of our podcast on Spotify, Apple Podcasts, and on backtable.com. Welcome back to another episode of BackTable OBGYN. This is your host, Mark Hoffman. I've got with me once again, Dr. Amy Park. Amy, how are you?
[Dr. Amy Park]
Great. How are you, Mark?
[Dr. Mark Hoffman]
I'm good. I feel like we haven't gotten to hang out in a little while. This is great. I missed you. I missed hanging out with you.
[Dr. Amy Park]
I know.
[Dr. Mark Hoffman]
We have once again, a great guest. This is somebody but it's someone who I'm meeting for the first time but as a friend of a friend. Dr. Lisa Hickman, who's here from The Ohio State University. She's a clinical associate professor of OBGYN and a urogyn and reconstructive surgeon. Lisa, welcome to the show.
[Dr. Lisa Hickman]
Hi, thanks so much for having me. Excited to be here.
[Dr. Mark Hoffman]
Well, you came highly recommended from our friend, Dr. Urbina. We were excited you were able to join us. As we do for most our guests, we like to let our listeners get a sense of who you are. Tell us a little about yourself and how you got to where you are in your current position.
[Dr. Lisa Hickman]
Sure. I actually trained at the Cleveland Clinic for residency. When I went there, I was originally planning to go into REI based on some previous research I had done between undergrad and med school but then rotated on urogynecology and just realized I loved it. I ended up staying for fellowship. When I was a resident, actually, I realized that we really didn't have a good place or an aftercare set up for women who had advanced obstetric lacerations.
At the time, there were two really amazing groups that were doing research and had dedicated clinics in this area. One was Northwestern with Christina Lewicky-Gaupp and her Peapod Clinic, which you probably know. Then also at the University of Michigan with Dee Fenner. I just wanted to learn from them. I was so excited about urogyn, and I really fell into this clinical area as a subspecialty interest. I'm really excited to talk about it today with you guys. Now I'm at Ohio State. After I graduated from fellowship in 2020, I joined as faculty and have been there ever since and keep taking care of urogyn patients and this subspecialty population.
[Dr. Mark Hoffman]
That's great. I feel like Christina Lewicky-Gaupp was at University of Chicago before I was there as a resident. Then she went to Michigan, and I think she's part of the reason they let me come because she was so great. They're like those University of Chicago people must be Okay because she was so amazing. Then I got to go. I feel we've chased each other, but I never really got to hang out with her. One of these days, I'll have to get her on the show.
[Dr. Lisa Hickman]
She's amazing.
[Dr. Mark Hoffman]
It was with Dee Fenner at Michigan where I saw the first-ever postpartum clinic. That was something I had not ever seen before. That was pretty amazing.
[Dr. Lisa Hickman]
I had the opportunity when I was a resident to actually go up to the University of Michigan and shadow in the clinic and see what their model was. They were really formative as I developed my own at the Cleveland Clinic.
(1) Pregnancy, Childbirth, & the Pelvic Floor
[Dr. Amy Park]
This is something I saw it develop in the field because Christina is actually a good friend of mine. Watching the work in this space, it's really amazing how much has been elucidated just in terms of the physical changes, the emotional impact, all the things. 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.
(2) Perineal Tears: Risk Factors & Prevention
[Dr. Amy Park]
Tell us a little bit more about those tears. How do they occur? What can we do to prevent them? I think a lot of people don't even realize when they fill out their birth plan that that could even be a possibility. There's forceps, there's vacuum, there's higher order tears. Just tell us what the risks are with all the modes of delivery.
[Dr. Lisa Hickman]
We know that there are some pretty well-defined risk factors for more advanced tears during delivery. Operative vaginal deliveries confer the highest risk. When you put a midline episiotomy in addition to that, it increases the risk even more. Larger babies, typically in studies, it's more than 4,000 grams at the time of delivery. Occiput posterior position because the fetal head diameter is increased. Asian ethnicity is actually a risk factor for an increased order magnitude of tear.
[Dr. Amy Park]
You know why that is? That is because it's a shorter perineal body. Speaking from personal research.
[laughter]
[Dr. Amy Park]
I actually didn't know why. Then it just has to do with just the anatomy of it. It's a safety zone. If it's 8 centimeters, you probably aren't going to have a fourth-degree tear. You know what I mean? If it's two and a half.
[Dr. Lisa Hickman]
Right. Two and a half and less has been what's typically quoted. Yes, if there's less anatomic distance to traverse before you're in the anal sphincter complex, then you're more likely to have the tear first, definitely.
[Dr. Amy Park]
What are things we can do to prevent it? Sometimes things just happen, right?
[Dr. Lisa Hickman]
Right.
[Dr. Amy Park]
Is there anything we can do to prevent these higher magnitude tears or levator avulsion during childbirth or whatever? What are the things we can do to prevent this? Do some more core, look at pilates and bar or what?
[Dr. Lisa Hickman]
I think having pelvic floor awareness is a really interesting concept. I don't have any data to support that, specifically, but the physical therapist will talk about proper pushing mechanics.
That's something that we-- when I send patients in pregnancy to physical therapy, something that I'll tell them that they can work on with their physical therapist. As far as what research studies have been done in the past to look at reducing severity of tear, we know there are a few things. Perineal massage, patients can do that starting in the third trimester. You have to do it pretty regularly, but the idea is that you increase the elasticity and the stretch of that tissue. It's a little bit more compliant when it comes time to have a vaginal delivery.
Warm compresses and labor have been shown to reduce the risk of having a higher-order tear. I know when I was a resident, there was a lot of focus on perineal supporting the perineum during pushing and during delivery. There's a little bit of data on sideline pushing. Then ultimately, if you have someone who you're really concerned that they have maybe a short perineal body at baseline, you could consider doing a medial-lateral episiotomy to offset that trajectory of force away from the anal sphincter complex.
Those are not perfect. They can be more painful. They can be bloodier to repair or associated with wound healing issues. If you're really trying to avoid that vector of force toward the sphincter complex, that's an option.
[Dr. Amy Park]
You know, I just saw a study that maybe it's still an abstract form, but it was how to push, and if it was short sort of pushes versus sustained pushing technique. I can't remember which one is better. I just did a–
[Dr. Mark Hoffman]
An important piece of the puzzle here but yes.
[Dr. Amy Park]
I know.
[Dr. Mark Hoffman]
Flip a coin.
[Dr. Amy Park]
I can't remember which one it was. I just tried looking it up really quickly online, but I think that's a big question about technique. You know how you're saying about the pelvic floor PTs because it is a question mark. I would assume it's a sustained controlled one, but I don't think people have control over it, really, when it comes down to it, but it is interesting.
I wonder about technique because that's one of the only things you can control during labor pushing and the massage, essentially, which the massage, I don't know if that changed. Mark and I are going to show our age. I don't think the residents did that. You'd have to get midwife or doula to do that probably. I don't even know if the doulas get in there. Do they do that now?
[Dr. Lisa Hickman]
I think it's supposed to be the patient initiating.
[Dr. Amy Park]
How are the patients supposed to do it? They have an epidural a lot of the time.
[Dr. Lisa Hickman]
No, starting at 32 or 34 weeks, doing it at home to really start increasing the-- That is a commitment. You have to be committed.
[Dr. Mark Hoffman]
Well, I think committing to that, understanding the outcome of not doing that or the potential consequences rather. Amy and I are both recovering obstetricians, but I think we probably have many memories burned in our minds of spending a lot of time at the perineum, trying to figure out ways to make it less challenging of a repair for the patient's sake, obviously. I think about all the different ways people told us to protect the perineum and those things.
The other thing that was always holding the perineum almost together, supporting it with a little four-by-four or something else I always was taught to do. I didn't have that many big repairs, but episiotomies were something that we were-- It was definitely in the time where definitely do them and then definitely don't do them. You mentioned that medial-lateral episiotomy. I guess, it's been a long time since I've done obstetrics. Is that something that's been pretty well-established that, in a sense, deviating or changing the angle of the tear is going to decrease the risk of getting a fourth degree? Is that something that's pretty routinely done?
[Dr. Lisa Hickman]
I don't think it's routinely done. I don't do obstetrics anymore, but I will oftentimes counsel women antepartum about who have had advanced tears in the past. It's like, what were your risk factors? I like to categorize them as modifiable and non-modifiable risk factors to understand, okay, what were your risk factors when you had your first delivery with your advanced tear and then what is still going to be a risk factor this time around, and what could we reduce the risk or won't be a concern.
(3) C-Section vs. VBAC: Balancing Risk & Patient Preference
[Dr. Lisa Hickman]
For many of these patients, we know that when given the choice, 65% of women or more would pick another vaginal delivery in the future. I think sometimes the discussion isn't a binary decision of C-section versus vaginal delivery. It's when you would stop the line. Having some of those strategies really, I think, empowers patients to feel like, "Okay, these are some things that are in my control, and this is what I'm okay with. This go-around, but this is what I'm not willing to do again."
Those are nuanced decisions, and they're ones that I 100% engage the obstetrician in the discussion because I think it's really important to take a team-based approach here. I'm not going to be in the delivery room or typically doing the repairs, and these are really difficult situations most of the time.
[Dr. Amy Park]
I think that is one of the things that is really hard to say. I saw one of my neighbors actually in DC and she did VBAC and she devolved prolapse and incontinence. She told me, "Had I known I could develop this, I would have just gotten a repeat C-section. I never would have done a trial of labor after cesarean." It's just like one of those things that people don't think about when they're counseling because there's so many other things that people have to think about.
[Dr. Mark Hoffman]
One of my friends who's a urogyn and said, "I will not have a vaginal delivery." She was like not interested in any way in having a vaginal delivery. She sees a lot of the consequences of that but was not being dramatic about it. She just said, "If I can avoid it, then I should." Not that C-sections are without their own series of potential complications. To her, it was very important, and I know that her obstetrician was happy to do it.
[Dr. Amy Park]
I also had elective C-section. You had vaginal though, right, Lisa?
[Dr. Lisa Hickman]
I would say, actually though, probably if you surveyed urogyn, and maybe this is a research idea, but-
[Dr. Mark Hoffman]
Oh, that would be so interesting.
[Dr. Lisa Hickman]
Most urogyns actually do have vaginal delivery is what I think. I think we have a higher rate of elective C-section compared to the rest of the population, and that's all relative, but the majority still have vaginal deliveries. I will say elective C-section on demand was a big deal. I was just thinking about this in the car the other day. Tony Visco went to NIH to push for this. Essentially, I think the obstetricians just were like, "No." [laughs] Higher order C-sections, you were talking about a five-peat, that increases the risk of a creda, increda, percreda, all the things, bowel injury, you name it.
As a public health perspective, I agree when you talk about a quarter of the pregnancies in this country are unplanned. Maybe those numbers have budged, but usually, it's been about the same. Then you're talking about all of these unplanned pregnancies and then setting forth this path of repeat cesareans. I don't think it makes sense from a public health perspective, but on an individual level, it seems to make sense.
It's like sometimes these things diverge, but you have to be committed to birth control and not having lots of deliveries. Although we do have five-peats and they do fine, but it's just not a strategy. In Brazil, everybody's getting C-sections, but that's not necessarily a good thing, I think. I don't know. I feel conflicted about it because it's good for me, it's not good for somebody else. It sounds elitist or wrong in some sense.
[Dr. Mark Hoffman]
I think there's information asymmetry in medicine. There's nothing we can say about that. The same way is like I don't care how many times a guy fix my car tells me about it. He just knows way more. You guys have a level of understanding of a complex thing that it's really hard to communicate, to truly understand what that means, at least when you're making a decision about yourself and your own body. Yes, I and Amy would be fascinated to see the results of that survey because I've heard it from more than one urogynecologist, and no other non-medical people have ever said, "Oh, I'm just going to do that." Not one.
[Dr. Lisa Hickman]
Yes. I think Victoria Beckham brought all of the national media with the whole being too posh to push. I think that term was coined from her, but previously, I think it really had been that all women should be expected to have a vaginal delivery. I think there is a lot of merit to that. I actually was induced and ended up abrupting and having a crash section and the only way that a healthcare professional could do.
This was a decision was one that I considered very heavily in my first pregnancy because I knew I was the only one that could make such an informed decision about what was right for me, as you were saying, Mark. I did think if we have multiple children and then I end up on the accreta spectrum in a subsequent pregnancy, I would have been so disappointed that I didn't give it the old college try.
[Dr. Lisa Hickman]
It is such a nuanced decision, but it also is I think really important that we do patient-centered care and discuss really risks and benefits with them. Another shout-out to Christina Lewicky-Gaupp. I know when she was at Northwestern, she really made a lot of inroads with the way that they counsel patients about obstetric delivery and operative deliveries and the risks associated with that. In her clinic, she kept hearing patients say like, "Gosh, no one told me about these risks."
These are the things that I hear in my clinic, too. When I see women who have had a third or fourth degree, they come in, with fecal incontinence, a lot of pain, wound healing abnormalities, and they say, "Gosh, no one told me these risks." Now, ultimately, we all know in healthcare, there's no way to counsel patients about every single risk, especially when you have a full clinic day and patients back to back.
Again, these are complex discussions, but I think that this is where you really should meet your patient where you're at and find out what are their concerns. What do they know? What don't they know? That's where we maybe also leverage the fact of some standardized processes, which is what I think Christina was pretty successful with.
[Dr. Mark Hoffman]
I agree. I think it's something that so much and understandably and probably appropriately, so much about pregnancy is focused on the pregnancy, the fetus. Everything needs to be a certain way to make sure this thing turns out the way we want it to turn out. I don't know that I remember hearing a whole lot about the pelvic floor or mode of delivery for a patient who was in their first pregnancy, just wasn't really part of the conversation at the very least, bringing awareness to that conversation. That was something that working with [unintelligible 00:21:24] in her clinic describing labor as a sports injury.
We tear muscles and you, all these things happen that in sports, you would go have surgery. These things impact their lives in such profound ways that there's no discussion before. There's more so now because of what people like you were doing, which is not as common as it needs to be. The discussion afterwards too, though, bringing awareness to the issues, the impact of labor postpartum too.
I worked at the VA and I would see patients that had urogyn issues and chest incontinence and I was like, "Oh, let me refer you to my colleague, a urogynecologist." I'm like, "Wait, that's something you can fix?" These are young women, 30s, 40s. I'm like, "Yes, there's people who specialize in this. That's their whole job is to help people dealing with the problems that you're dealing with." She's like, "Oh, my whole running group, we just put on pads. It's like we just all talk about how this is going to happen the rest of our lives." I'm like, "Well, actually, it doesn't have to."
They had never heard of a urogyn or pelvic-- We joked about it earlier, but whatever you guys are calling yourselves these days, but they'd never heard of urogynecology. They'd never heard of solutions to leaking it, just "Oh, my mom said, this is just what happens when you have kids." The fact that you're bringing awareness or you're putting these clinics together is so important for patients to know that this is something that's very common, not normal, but exceedingly common and oftentimes undertreated.
(4) Common Challenges in Postpartum Care
[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 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.
(5) Mental Health Support for the Peripartum Patient
[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. Amy Park]
I was going to say, and also the access about the mental health. I had this patient who had a fourth degree after a forceps. The thing kept on breaking down. She had a multi-drug-resistant bacteria growth. I couldn't get it. Remember I called you about this lady?
[Dr. Lisa Hickman]
I do remember.
[Dr. Amy Park]
She was a dentist. She became my dentist. Then she looked at my teeth, and then she was like, "Do you remember me?" I was like, "[unintelligible 00:27:46]" [laughs] Are you sitting okay? Anyway, she endorsed suicidal ideation, and then we put in a stat consult. It was large. They did not get her in until July. This is not right. This is not an uncommon thing. You guys aren't even surprised about this. It's so terrible.
[Dr. Lisa Hickman]
You know What? I have people I can tap and say like, "Hey, I really need help with this patient." Thankfully, I've created this nice little network so that we can really make some pretty quick inroads if we need to for a new mother.
(6) Opening a Peripartum Clinic: Key Considerations
[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 urogynclinics 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.
(7) Expanding Access to Pelvic Floor Physical Therapy
[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.
[Dr. Mark Hoffman]
It's incredible. One of the things I noticed when I came to the University of Kentucky, there wasn't a huge PT program, and there weren't a lot of therapists. We see a lot of folks from outside of the city. They're going back to their small towns. We would just continue to write referrals, write referrals, and they would go to these local PT places or hospitals. Now there's probably a dozen in hospitals and places around the state that they just kept getting referrals from us. They said I guess we should probably hire somebody.
We've got a network of PTs that went and got training and realized the hospital saw that there was a need for it. Sometimes just educating patients and having patients demand it where they are because it's not something you can drive three hours for multiple times a week. It's one of those things that it's a slow build, and it's a community build more so even than just an institutional build but something that is such an-- I obviously did get a lot of pelvic pain, but I'm a MIG surgeon. So much of what we do is not my surgery or my prescription, but it's the expertise of our Pelvic Floor PT colleagues. I just can't imagine caring for these patients without them. It's really amazing.
[Dr. Amy Park]
It is a little structural difference though about Pelvic Floor PT because just like PEDS urology or PEDS in adolescent gynecology, it's like you get more training, but it's not like you get paid more for this extra training. You have to do all this extra certification. You have to get a private room. There's all these things that go along with being Pelvic Floor PT, and then you can't see as many patients or whatever. It definitely attracts therapists who are passionate about women's health, which is amazing and awesome. There's never going to be enough supply for the demand, and that's a problem.
The other thing that I think is super interesting about the role of Pelvic Floor PT is and correct me if I'm wrong. If you look at all the meta-analyses and the Cochrane reviews, every part of Pelvic Floor PT just prophylactically has never been shown to any-- have any benefit. That's not to say if there's a diagnostic issue like a true issue of therapeutic benefit, there is, and we all do it. People sometimes are self-flagellating coming in and saying, "Oh, I should have done some more kegels before delivery." You're like, "Well, it really doesn't help."
[Dr. Lisa Hickman]
I think something that's tricky there is that there's so much human element with physical therapy. They spend one hour a week or one hour every other week working one-on-one with a physical therapist, but it's really the time the patient puts in outside of those sessions. That I think is where it really makes Pelvic Floor Physical Therapy challenging to study the impact sometimes because of that human element.
[Dr. Amy Park]
It's true. If you look at the optimal trial for urogyn, perioperative Pelvic Floor PT, pre-op, post-op, around pelvic, reconstructive surgery didn't make a difference. Same with the slings. It helps with that subgroup that have urge basically is what it shows.
[Dr. Lisa Hickman]
You know what, social media and ads being served to patients and TikTok and everything else, I'm just curious, what is the role going to be of these home pelvic floor trainer devices, especially as they become more popular, can patients comply to it more? There's been some good studies that have looked at different devices for stress incontinence.
One thing that's cool about these studies is that they can actually see how compliant patients are with the device. Even one of the studies, they asked patients how compliant they thought they were. Then they audited the device and the least compliant patients definitely rated their compliance higher than what it actually was. At least, it then creates some control of okay, when people do pelvic floor muscle, regimens regularly, what benefit do we actually get?
[Dr. Amy Park]
They're not alone. I always say surgeons always overestimate their volume, underestimate their EBL, and their operating room time. I've said this a million times, but he knows because he wears the OR and the CMO hat. [chuckles] It's like we're all delusional. There's no–
[Dr. Lisa Hickman]
I know.
[Dr. Mark Hoffman]
Show me the data. It's fine. You can tell what you think you know, and let me just tell you what it is.
[Dr. Lisa Hickman]
Exactly.
(8) Advanced Tear Repair Best Practices
[Dr. Mark Hoffman]
Let me ask you a question with LNDRs. When there's a tear, how much does the actual repair at the time? Occasionally, you guys get called in. It's not really the on-call situation at every place, but certainly, it's something that can be complex repairs. How much do you think the repair at the time impacts the long-term outcome from a third, fourth-degree tear?
[Dr. Lisa Hickman]
That's an interesting questions. There has been some data looking at this of who does the repair. Can that affect outcomes? There is some data suggesting that repairs done by midwives on more complex tears can be associated with higher rates of wound complications. That being said, at least at our institution, our midwives do a great job of evaluating the patient, but then we'll call in higher order trainee or physician to do the repair.
I think that, again, those in the labor and delivery room is the least optimal situation. I think it is a shot to definitely do the repair well. I advocate if it's a complex tear, move the patient back to the OR, get proper equipment, get better analgesia, get improved lighting, and then do the tear to the best of your ability. I think a digital rectal exam goes a long way as well to just really evaluate the anatomy and know what you're working with and make sure that you don't miss something.
In that regard, I do think that there are opportunities when you do have the tear to do it the right way the first time. There are also the ACOG practice bulletin recommends a dose of antibiotics like a cephalosporin if you have a third or fourth-degree tear at the time of a repair unless they've received antibiotics for choreo or something in labor already. I think that has been shown to reduce the risk of wound complications as well. There certainly are things in the provider's arsenal that they can do to do it right the first time.
[Dr. Mark Hoffman]
I want to make sure it's clear. I'm not saying this with any judgment as someone who did a four-year OBGYN residency. I've done my share of deliveries. I think I saw one fourth degree. It just it wasn't something I saw a lot, let alone-- We delivered boatloads and boatloads of babies while we were in residency. It just wasn't something I did a lot when I was in training. When you get out, again, it's just not something you see. What is the rate of third or fourth-degree repair in an SVD?
[Dr. Lisa Hickman]
Depends on what study you look at, I think 4% to 11% is the incidence of a third or fourth-degree tear. I think it also depends, are you at a center that does a high volume of operative deliveries because that certainly increases risk? You're right. the point you're making, Mark, is spot on because we know that there are studies saying that trainees leave residency and don't feel comfortable managing advanced tears because of the infrequency with which they happen, and you're right. If 80% of women have a tear during a vaginal delivery, the vast, vast, vast majority are going to be first and second-degree tears. How do you get good at something that you only do a couple at?
[Dr. Mark Hoffman]
How do you recognize it? How are you comfortable making that assessment to even know? Again, I say this with some distant memories of going, "I don't even know what I'm looking at." Then someone comes and goes, but it's to say, it's not an easy thing.
[Dr. Lisa Hickman]
No, it's certainly not.
[Dr. Amy Park]
I do remember one study just on the-- going back to technique. There's Green Journal study, and they looked at overlapping versus end-to-end. Actually, surprisingly, end-to-end at the time of delivery did a little bit better. I don't think it was that big of a difference, but this was maybe 10 or 12 years ago.
[Dr. Mark Hoffman]
You're talking about external sphincter?
[Dr. Amy Park]
Yes, for external sphincter repair. We usually use the SCAR to do an overlapping if we can, but it's associated with a little bit more dyspareunia with a delayed repair, I think. Here, at least we don't get called in for third or fourth-degree tears, but I have colleagues who say that they get called in all the time. This just brings up that question of like you're saying, if you don't see that many, do you feel comfortable doing it? Then it's just like that is a training problem creating itself as well.
(9) Effective Training for Advanced Tear Repair
[Dr. Amy Park]
Obviously, we don't want to have more third and fourth-degree tears just for training or what have you. [chuckles] I think prevention is key and we want to do that. It is interesting. If you look and forecast what the training is going to be like for third and fourth-degree tears, it is good for the residents to train and know how to do it, right?
[Dr. Lisa Hickman]
Right. We have opportunities educating trainees on anatomy. We just actually this past week did a urogyn SIM session for all of our residents. I think SIM goes a long way where you use the low-fidelity models of how to repair and what the anatomy is, so people get used to the steps. I think, just giving people the tools and their armamentarium like, "Okay, first, if you don't know what's going on, start with a rectal exam, and then get a sense of the anatomy, get some irrigation or suction, even if you're in the labor and delivery room and then know what to ask for."
I really thought it would be interesting to have like a pick sheet in the labor and delivery room to make it easier for people like, "Okay, we have a third-degree tear, grab the kit, grab the antibiotics with extra tools, and the suture you need," to make it almost a little bit formulaic. Obviously, again, I hope that it comes off with the utmost respect that I have for what obstetricians do because those are really, really complicated, tricky repairs, but to just standardize it and make it easier. I think SIM and just really good foundational knowledge can be really helpful for going a long way with this situation that is not that common.
[Dr. Amy Park]
I agree with you about, I love the patient ed that you did, because I think a lot of this about surrounding pregnancy and childbirth and just surgery, in general, is managing expectations, not just surgery, medicine. These are things that can happen with a normal delivery, and nobody did anything wrong. It can happen. People are educated that this could be a possible sequel.
I think people naturally go into surgery with knowing or expecting that sometimes things can go wrong. It's intuitive, but I don't think that that's just the same thing with labor and delivery. Then what you're saying about the best practice alerts on the EMR about the pick sheets, about the education, about getting the antibiotics? There's all of these protocols. I know people don't like protocols sometimes because it's formulaic, but I think formulaic saves lives.
I think Mark is in the middle of doing all this quality work, I'm sure all the time, but we just rolled out a sepsis OB, sepsis epic set, the labs you're supposed to order, and the things that you're supposed to do in order to treat the patient. I think that all of those things are a really good point. I remember when I was a resident, every postpartum hemorrhage, 10% of deliveries end up in hemorrhage. It was like the next time was like the first time every time you went up to the floor. Nobody knew what was going on. Nobody could start an IV. There wasn't equipment available. If you just had a set you could just grab.
[Dr. Mark Hoffman]
Then we're like, "Oh man, we were heroes. We really swept in and fixed it all." "Yes, but you didn't have to. You could have completely been ready for that ahead of time." I always use this analogy. There's a baseball player, Jim Edmonds, who always won golden gloves for making these great diving saves because he was always out of position. The other guys are just standing there and catch the ball because they're where they're supposed to be. He's running to do it. Set yourself up to succeed, be in the right place, have everything prepared ahead of time. We don't need to be heroes. Just it should be boring and formulaic and just do it the same way every single time.
When there's a variation, when there's something outside of that, you recognize it because it's outside of that norm. Man, people love to just do it their way. Yes, Amy, you said, I'm a much more of an administrative role these days, and getting people to do the right thing is a challenge.
[Dr. Amy Park]
Also, when you're in the thick of things, it's hard to remember all the things that you need. You know what I mean because it's like there's a lot of blood happening. There's a lot of chaos, there's screaming, there's 20 people in the room. Making this as easy as possible in a chaotic situation is key. That's why the SIM for doing obstetric emergencies, the SIM for the beef tongue model for the lacerations, I think is all key. Then just educating the whole team on what to do is also key. I think that these are all little things that very difficult in practice to do.
You created a team and you created awareness. I know when you were just leaving as I was coming, but you were so passionate about it. I think your passion for this was infectious. I think that's why also people got on board because people understood that there was a gap. There's not enough of you. You probably could do this like your whole practice. No, because there's just so many.
[Dr. Lisa Hickman]
Yes, there ends up being way more people than what you would think. I was so humbled when I started at a Cleveland Clinic, and it was such a success that I knew I just had to do a beta model and rebuild it at Ohio State and same thing. We have seen some really interesting patients. We have seen a lot of uncomplicated patients, but those patients leave with education, and they feel empowered.
Actually, Katie Probst and Cecile Ferrando and Alexander New Titus just published recently a qualitative study where they interviewed women who had OACI. The big three themes were their desire for pain control, for multifactorial support, and then OACI knowledge and awareness. That's some of the things that we are addressing with the clinics, which is really cool because it matches up the needs of what patients want and what we're able to deliver.
[Dr. Mark Hoffman]
That's wonderful. It is a testament, not just to your passion and hard work, but also that you're able to build it in a way that's sustainable. The fact that you've left and gone somewhere new and it's still going where you were. That's something that is so valuable to me to know that when folks are out there building things, it's not just it's only me, only I can do it. You're seeing it in a way that like, "Let's do it in a way that other people feel a part of it." We build the team. Even when you step away, it's sort of self-sustaining. That's it's a hard thing to do. It's something I value personally very much, especially in what I do today.
It is a testament to your efforts, to your hard work, and your commitment. It's very cool that you've done what you do. Thank you so much for your time and for coming on the show because I think it'll allow some of our listeners to think, "Well, I should be able to do where I am, too." I think it's something that patients need. There's a there's a there's no question there's a gap here. Thank you so much for talking about your program and all the work that you've done and tell everybody at The Ohio State that I say hello.
[Dr. Lisa Hickman]
I will. Thank you so much for having me. Truly one final little plug. Anyone can do this. If you are someone who's listening and this is something that's interesting to you, I have helped other people. I would be happy to help you figure out what a model could be. Just reach out to me. I'd love to help.
[Dr. Mark Hoffman]
For our listeners, they can contact the show, and we can always make that connection as well. We can put a link to your website in the show notes as well, just so people can see what it is that you do. What a pleasure.
[Dr. Lisa Hickman]
Thank you so much for having me.
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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