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Almost 2.5 million American women gave birth to their babies through vaginal delivery in 2021. Doctors suggest that about 100% of those new moms experienced some pelvic floor changes postpartum.
"It is just something inherent in having a vaginal delivery," says Carolyn Swenson, MD, a urogynecologist and Chief of Urogynecology and Pelvic Reconstructive Surgery at University of Utah Health. "Your pelvic floor muscles and connective tissues undergo stretching and sometimes tearing and other changes that don't go back to exactly how they were before delivery."
Most women who have vaginal births will recover from the injuries to their pelvic floor less than two months postpartum, but up to 1 in 3 require more specialized treatment. It is these women that Swenson and the team at the University of Utah Peripartum Pelvic Floor Wellness & Recovery After Delivery Program (UPWARD) want to help.
One group this program focuses on is women who have had more extensive obstetrical tears such as those that involve the anal sphincter muscles, also known as 3rd- and 4th-degree tears. According to Swenson, those types of tears occur in anywhere from 2-5% of vaginal deliveries. "That risk is a little higher if you have had forceps or have a large baby," she says. "We know women with these tears have already had more pelvic floor injury than average and we want to make sure they recover well."
Zoe Perkins' pelvic floor injuries were extensive following the birth of her son in March 2022. "My pelvic floor injury was a 3C (3rd-degree) tear from a delivery with forceps of my kiddo," she says. "That caused me to have fecal incontinence. Because of the severity of my tear, before I left the hospital, I had a referral for Dr. Swenson to look at my pelvic floor function."
In the days leading up to Perkins' postpartum exam, the challenges brought on by the severe tear to her pelvic floor were piling up for the new mom. "I couldn't hold my stool," she says. "And if I had an urgency, I couldn't make it to the bathroom in time, even from my living room sometimes."
Following an initial exam, Swenson referred Perkins for treatment with a team of pelvic floor physical therapists at U of U Health. And despite a backlog of appointments for these services, Swenson was able to get Perkins the care she needed in a timely fashion.
"What was cool about that experience was the ability of Dr. Swenson to know the severity of my injury and know that pelvic floor therapy would be very beneficial for me," Perkins says. "In order for me to work on my fecal incontinence, I needed to get into therapy, and she made that happen."
Pelvic floor physical therapy is one of the primary services Swenson and the UPWARD team refer their patients to who are experiencing urinary and fecal incontinence.
"When women go through childbirth, the muscles in their pelvic floor undergo these stretch injuries and swelling and sometimes tearing of the muscles that require a level of rehabilitation that we just haven't really focused on in the past," Swenson says. "So pelvic floor physical therapy is one of the main strategies for rehabilitation of the pelvic floor postpartum."
The individualized care Perkins received certainly helped her to tackle what can often be an overwhelming time for women who experience much easier births. "Over the subsequent months, I followed up with the physical therapists and then also with Dr. Swenson and ended up getting an endoanal ultrasound that showed my stitches and my injury had fully healed," Perkins says. "Now things are good."
The idea of a clinic that assists and directs women who are battling pelvic floor disorders to specialized treatment is a relatively new one. From 2015 to 2021, Swenson helped run a first-of-its-kind program founded in 2007 at the University of Michigan. The UPWARD program at U of U Health opened in 2019 and serves a steady stream of patients from Utah and surrounding states.
"I think there is an increased awareness of these conditions affecting postpartum women," Swenson says. "The younger generations are not as accepting of the answer, 'Well, you just have to live with it.' And that is good because that's not true and these women deserve care. They deserve to have access to these specialty clinics. While more women are aware of pelvic floor disorders today, there is still a huge need for increased understanding of these conditions."
A primary goal of this program is patient education. Patients receive information about their specific pelvic floor condition and tailored counseling about the impact of future pregnancies and deliveries on their pelvic floor health. In addition to referrals to pelvic floor physical therapy, UPWARD also collaborates with experts in musculoskeletal disorders and perinatal mental health to help provide comprehensive care.
How to handle a second pregnancy is an issue Perkins has been grappling with since she now medically qualifies for either a vaginal delivery or a C-section due to the extent of her tearing with the forceps delivery. Swenson has offered her the care and counseling to make that choice when the time comes.
"My experience made me realize that I didn't understand the potential of a forceps delivery and a tear affecting how I would approach a future pregnancy," Perkins says. "But [Swenson] has empowered me to understand my options in the future."
The team at UPWARD is focused on the effort to empower as many women like Perkins as possible with the specialized treatment and counseling they need now and into the future. Swenson believes they deserve it. "Having this specialty care is not only important for our patients' physical recovery but their emotional and psychological recovery as well."
