Hi there. I'm here today with Peyton Schmidt. She's a clinical assistant professor at the University of Michigan in urogynecology and pelvic reconstructive surgery. We're going to be talking today about their healthy healing after delivery program, which is the first program of its kind in the U.S.
offering support to women after their childbirth who are experiencing. Third and fourth degree lacerations, episiotomy issues, um, bladder leaking, stool leaking, constipation, trouble emptying their bladder, painful intercourse, and pelvic floor dysfunction. So, um, thank you so much for being here today with me.
Can you tell me how this program got started? Yeah. So Dr Fenner, who is now our chair at the department, uh, started this healthy healing after delivery program, um, mirroring it off of the group, um, in the U.K. where Dr, um, soccer and Sultan are, and they have really done a lot of research, um, mostly focused on, uh, obstetric anal sphincter injuries.
But as all of us, you're a gynecologist. No pelvic floor disorders are unfortunately very common after virgin vaginal birth and pregnancy in general. And so this this clinic was created to help women that were struggling with pelvic floor disorders or dysfunction after recent delivery right now in the U.
S. Uh, this type of clinic is not really that common. So what kinds of things were women experiencing that we weren't addressing as well as we could be addressing? What, what things were we missing? Yeah, I think there is, there are quite a lot of things that need to be or should be covered in a postpartum visit.
And there's likely a lot more focus on, uh, you know, bleeding and breastfeeding and, uh, other important postpartum issues. And pelvic floor dysfunction was probably just not being, uh, as talked about as much as maybe it should have been or, or should be. Um, and so, These specialized clinics are a way to help women better understand what is normal and what is not normal with regards to bladder and bowel function and how they feel with regards to pelvic floor symptoms.
Um, and it also helps. in our mind, we're kind of helping them optimize their recovery after a traumatic birth. Who and how do women end up in the clinic? Are they sent by their OBGYN? Are they self referred? Do they, do they realize there's a problem? I mean, I think that's one of the issues here is, you know, when it's your first delivery, it's hard to know what's normal and what's not normal.
Cause we don't often talk about those nitty gritty details of what you're really experiencing. So at our institution, since our clinic has been around for quite a while, most of the patients that we see are referrals, um, many from our institution. So we have a pretty good algorithm for how patients get referred.
For example, if they had a third or fourth degree laceration, a forceps or a vacuum delivery. Or other, um, traumatic injury after birth, such as episiotomy, or really significant tears, or concern for levator avulsion, then they automatically get sent from our general OBGYN clinic. We have another hospital that's close by, um, where we see some of their more complicated, um, third and fourth degree lacerations, and other women that are having persistent.
Postpartum pelvic floor issues. Um, and then we do have a handful of patients who have specifically found us online, um, given their concerns and, um, self refer to get in. Um, so it's a mixture, but mostly we're being sent patients from our OBGYN group. Was that hard to start? I mean, Dr. Fenner is a very well respected physician.
Um, she is very well known. She has, you know, a great reputation, but you know, changing practice like that is hard. Was that a hard thing to get the general OBGYNs to refer to the, to the clinic? I think with every change, like you said, change is hard. And so it was an adjustment. I think now it is very much embraced at our institution because we are able to help these patients that really need a lot more attention and in a busy, uh, obstetric and, uh, general obstetric and gynecology clinic.
They might not be able to give that individual as much attention as they may or may not need. Um, and so it is very much something that's embraced now. Um, and at first it, it likely was more of an adjustment. Um, but I, I find that even our outside OBGYNs that know about us, they understand that we're able to give really tailored care to patients.
Uh, that the patients are really satisfied there have been there's been some recent literature that's come out just describing what is, uh, what, what sort of things are covered in a clinic like ours? What would you include? How do you evaluate patients? And, uh, Uh, there's good discussion of increased patient satisfaction, actually less litigation, particularly even, um, you know, with the OBGYNs that delivered the baby, even though we are not necessarily a part of that process.
Um, so I think that As people start to understand what we can provide and how it helps the patient as well as the local providers, it's really something that's been embraced. Um, so can you walk me through the, how the clinic works? I mean, let's pretend like I had a fourth degree laceration. It was my first delivery.
I'm referred to you. Um, when, when do I see you and who do I see and what happens? Okay. Yeah. So the referral, at least if you have had a laceration at our institution, the referral goes in on day of discharge that gets sent to, we have one main nurse who's our clinical care coordinator. Um, it gets sent to her, she calls the patient and we have a very structured, um, set of questions we go through that, um, involve, uh, any questions Questions are regarding the laceration, pain management, wound concerns.
We also cover any bladder or bowel issues. And based on how people are doing, what type of tear they had, we see patients typically within two to four weeks. We try to be on the closer side of two weeks if it's a fourth degree tear or Um, particularly if there's, you know, concern for a wound issue or a wound healing problem or an infection, um, and more on the four week side, if it is, uh, something of less urgent concern, how much of what you do is education versus, yeah.
A lot of education, even when my nurse calls, um, you know, she goes through, are they taking Miralax to keep their bowels off? Are they doing, you know, OTC pain medication such as Tylenol, Motrin, Sitz baths, warm compresses, those sorts of things to help with pain? Um, so she really Addresses the immediate concerns.
And then once they come into our clinic, we do a lot of discussion about what type of tear they had, what sort of expectations they should have with regards to how long it takes to heal, what are normal symptoms? Uh, what are normal things that they will, uh, experience during their recovery and then also how long recovery takes.
Yeah, I think the how long recovery takes is such an important part, right? Most women assume that they're going to be back to normal within six weeks and with some of these bigger injuries, that's just not the case, right? And so learning that you're. normal and what you're experiencing is so very, very important.
Um, what percent of patients end up seeing physical therapy? I offer every single patient, uh, physical therapy, and I'd say probably 90 percent of my patients accept those referrals. We're actually trying to do a study right now looking at, okay, you got that referral. Did you, were you able to follow up?
How long did it take you to get in? Cause, um, unfortunately we don't really have, we haven't figured out a great way to get the P.T.s into our clinic, uh, because of logistical type of, uh, issues. And so, and also P.T. is very variable in terms of what places cover what insurance. Right. Um, and so there are some other barriers that we're trying to get better defined so that we can address them better.
Do you offer any group classes for physical therapy or is it all one on one? Yeah, we've thought about that. We don't currently offer any group classes. I think there are some advantages and disadvantages to the group classes. Obviously there's lots of, uh, research around centering, certainly centering in pregnancy that can be really beneficial for patients because of that shared experience and, um, getting advice and help and support from others, um, but for a lot of the physical therapy that.
Is helpful postpartum, uh, pelvic exam can be a really important part of that, which is just more challenging to do in a group setting. So I think having a new baby is hard enough. And then when you have this kind of major trauma and you're healing from a major trauma, it is that much more difficult. And so I, I just think, you know, for me personally, I would love to have a buddy, someone who's going through something similar.
Um, and so that was really my reason for my. My question about group classes. Yeah, I think it's a great idea. We just have to figure out how to do it in a way that's helpful for everybody that logistically we can accomplish. But then also people can get that more private interaction. That's really centered around what issues they're having because it can be really variable, right?
One person can have more issues with stress urinary incontinence. And another person can have issues with persistent perineal pain from their laceration, and their physical therapy experience and what they should be getting done should be very, very different. Um, so just trying to work through those kinks will, will be an important.
Part of being able to effectively implement something like that. So you talked a little bit about outcomes and that, you know, patients are much more satisfied with their care. And, and I would think they, I mean, that completely makes sense. Have you looked at other outcomes from this kind of clinic? Yeah, um, one of our papers that came out a couple of years ago that was, um, our senior P.I. at the time was Carolyn Swenson, uh, looked at, uh, more of the surgical piece.
So when do patients present? How often are they needing to go to the operating room? Um, And how often are people needing revisions, which is a very small proportion. Typically, it's for people that have a wound to his sense or a fistula, um, in the setting of continued anal incontinence. Um, sometimes we are needing to repair, do like a perineoplasty to repair, um, or revise a laceration.
Um, so we've done studies on, you know, what sort of surgical experience happens through our clinic. We've also looked at, um, patients who level of regret or satisfaction with their decision to have subsequent vaginal deliveries after having an OASIS. Um, and in general, patients are satisfied with their counseling that occurred right after their OASIS, and then their decision to have a vaginal delivery in the future.
Um, we've looked at things like, um, de concurrent depression after, uh, a traumatic vaginal delivery. Um, so there's a lot of research looking at women's experience, uh, with more traumatic deliveries. Who do you image? Great question, . Um, there are certainly some clinics where it is routine for them to image, uh, all oasis patients, for example, um, with, uh, either trans peroneal or endo anal ultrasound.
Um, certainly I am, uh, doing endo anal ultrasounds on the patients that I'm concerned that they have a chronic defect based on their pelvic floor, um, symptoms. And then we also another paper I forgot to mention was we've looked at persistent pain. Um, and there's up to a third if. Women are having persistent pelvic floor pain up to three months or even four months postpartum.
MRIs do pick up musculoskeletal injuries such as pelvic fractures, osteitis pubis. Um, and, uh, pubic symphysis separation. And so I image women where the clinical picture's just not making sense. Are you doing any imaging looking for avulsions just to help patients, um, you know, kind of predict their pelvic floor future?
Yeah. Uh, no, at least in our clinic, we're not routinely imaging them looking for a volgen. Uh, I should have looked at this literature before this discussion today. Um, I, I can't think off the top of my head of what is the sensitivity of and specificity of, uh, imaging versus, um, Exam, but by palpation, uh, at least a major levator avulsion is often, um, easily detectable.
The thing that I think a lot of us that are doing this, um, more sub specialized, um, part of urogynecology. Is what is the value in disclosing to somebody the levator avulsion? Certainly if they're symptomatic, I think that's really important to discuss with patients and help them understand what they're experiencing.
Um, but in the asymptomatic patient, there's a lot of differing opinions on, um, you know, telling patients about levator avulsion, telling them about their risk of prolapse in the future and pelvic floor dysfunction. Um, because unfortunately we don't have any treatments for levator avulsion, uh, so it's. I think something that will continue to evolve as we learn more about what happens and how to properly treat these patients.
Yeah. It's such an interesting question at this point in time. When, when you say symptomatic levator avulsion, what kind of symptoms would you put in there? Yeah. Uh, I find that there is a group of women with levator avulsion who just feel off. And I, you know, it's a very big. Um, set of symptoms, but, you know, particularly women that were athletes in the past that are trying to get back to, let's say, really rigorous or long distance running, I think I find, um, are more symptomatic.
Where they just don't feel like they have the stamina or things don't feel supported or they don't feel stable, um, can be, uh, things that patients, symptoms that patients describe to us, but it is really vague. Um, and so it can be really challenging. I see that group of patients too. And it's interesting that you brought up kind of that elite athlete, because I feel like those patients do understand how their bodies work so much.
Uh, just on a different level than most of us do, right? And then when it works differently, they, they, they just know it's, it's working differently. Yeah. They're very sensitive that something has changed. Yeah. And, and I think what you said, I, I didn't actually think about this before. I mean, in my clinical practice, I see a lot of patients who have prolapse and have levator injuries, right?
You can definitely feel it on exam. Um, And they've never been told that, right? But that's very different than your clinic, right? Where you're seeing patients post postpartum, um, and, and you're doing that same evaluation and, and you can feel it on your exam too, right? Most of the time when people are being evaluated in that postpartum period, no one is thinking about the, the muscles.
On the level that, that you're considering them, do you, so, so this is a total aside question, but do you ever think about offering patients pessaries who have avulsions to help prevent prolapse? Oh, this is, uh, I only am like chuckling a little bit in the background because this is definitely, I think, What a lot of people are, are talking about, we actually have a physical therapist who's getting her Ph.
D. in our research group, and we've been talking a lot about, um, the role of pessaries, uh, for postpartum recovery. And we're very, we're trying to get together, um, and apply for grant funding to look at how pessaries can be used. I mean, there's the levator avulsion part of this, but there is a lot that we don't understand about level three pelvic floor support and the genital hiatus and how that plays a role long term in prolapse development.
Um, and there's a lot of interest and focus in our research group on the genital hiatus and, uh, interest right now and how a pessary potentially could help with genital hiatal, um, uh, recovery. Yeah, that's really interesting. Um, I, I will, I will be looking for that, right? I hope that we get some funding too.
I hope you get it too. Um, it, it's just such, you know, a pessary is just such a very benign intervention. And I just, um, I love the idea of anything that puts me out of business, right? Anything that, that helps prevent the injuries that these women get. And, and I think, you know, a lot of times. When women are postpartum, you know, a pessary just makes them feel better as they're healing and they're regaining muscle and nerve function.
Have you thought about adding in more antenatal care? We have a lot of discussions. Um, so we haven't necessarily thought about it through healthy healing, but what we're trying to work with our general OBGYN group, um, is somehow fitting into that. You know, second or third trimester teaching or having a class, um, that's available to all patients and encourage to all the patients that discusses pelvic floor.
Uh, function in pregnancy and then also postpartum so that patients know to reach out if they're having stress incontinence, like how many patients have you met in their sixties that were like, well, I just figured this was my life now after I had my bad, my first vaginal delivery, uh, and I've been living with it for 30 years and I just don't want that for patients.
I want them to say, Okay. Leaking on myself, no matter what age isn't normal. And, um, knowing that they can reach out for help and not suffer with it for potentially decades. Yeah, I, I should tell you that I'm at an age now where I get together with my college friends. I recently saw a college friend that I hadn't seen years this week.
You know, we're starting to have those discussions, right? Where, you know, these great, beautiful, wonderful friends of mine will say, Oh, I haven't run in years because, you know, I've been, I've been leaking since my first delivery. And you're like, what? Why didn't you call me? Well, it, I mean, it's, it's interesting when you see it in your patients and then you see it in your friends and you realize how ubiquitous that thought is that this is a normal part of aging.
And it's something that we have to accept, which is, I mean, it's common, but it definitely should not be considered normal. So, Yeah, I mean, I think all of the education we can do is great. I mean, I really like the nice guidelines from the U.K., right, where they think all of this should be started in sex education, right, which would be an amazing thing.
I don't know that we're there yet. But I, I think these are things that, uh, women should know, but I also think it's, you know, it's a fine line between educating people and terrifying people. Yeah. I think that goes back to, you know, I, the levator avulsion, I would love to do a study on what are people's practices avulsion with people.
What are patients experience and learning about levator avulsion or not learning about their levator avulsion. Um, and it, it, it's just something we don't totally understand yet. Um, so yeah, I think that most people aren't taught anything about it. And a lot of women with the vague symptoms that you describe kind of live with it, uh, bring it up to some physicians.
Um, maybe are educated about it. Maybe aren't. And then eventually stop bringing it up, right? It's something that we, you know, we need to do a better job of finding those women. So I think that goes into to, you know, it's a Public floor problems are not discussed a lot. They are certainly starting to be discussed more, which I think is great, but even taking the education out of like pregnancy or a medical realm and taking it to like.
Let's go on a, you know, morning talk show and talk about it so that people are hearing about it. It's becoming more, it's something that people better understand when it's normal or not normal. Yeah. Yeah. I mean, I think that's one of the reasons that I'm doing this podcast, right? Is I think that we need to just increase the conversation, right?
And start talking about these things. Um, so that it isn't so surprising to women when they experience these things. I, I love it. I think it's great. Yeah. Well, thank you so much. I really appreciate your taking this time with me on your very, very busy, um, work day. Well, I appreciate the invitation. It was a great discussion and, and I'm glad that, like you said, we're just making the conversation more heard.
Yeah, and I, I think, you know, I think we're all used to speaking to each other, right? Urogynecologists are used to speaking to urogynecologists. You know, I'm great at speaking to women in my clinic, but I want women who aren't ready to come to clinic or don't know to come to clinic to be part of the conversation too.
So thank you for helping me with that. Yeah. Thank you again.
