Advancing care for childbirth-related pelvic floor disorders

May 30, 2024

Multiple changes that occur during pregnancy and childbirth can affect the nerves, muscles and connective tissue in the pelvic floor. The compression, stretching or tearing that often accompanies pregnancy and childbirth can lead to pelvic floor weakness or pelvic floor dysfunction (PFD).

PFD is the inability to control and coordinate the pelvic floor musculature. Because the pelvic floor musculature supports the uterus, bladder and rectum, postpartum PFD symptoms can include urinary incontinence, fecal incontinence, prolapse, pelvic girdle and low back pain. In some individuals, postpartum PFD symptoms resolve over time after childbirth. However, these symptoms and problems can persist for many years and impact multiple facets of an individual's quality of life, including physical, social, emotional and sexual health.

"During the postpartum phase and beyond, pelvic floor PT (PFPT) treatment plans are designed to help reduce or eliminate PFD symptoms and long-term sequelae that affect patients' quality of life."

— Nikki J. Ron, P.T., D.P.T., WCS-ABPTS

In this Q&A, Nikki J. Ron, P.T., D.P.T., WCS-ABPTS, explains the evolving role of physical therapists in pregnancy and postpartum care, and how the multidisciplinary approach employed at Mayo Clinic is helping reduce long-term sequelae associated with postpartum pelvic floor dysfunction. Dr. Ron is a physical therapist specializing in pelvic floor health at Mayo Clinic in Rochester, Minnesota.

Why should PT be part of a pregnancy and postpartum care plan?

We know that the pregnant body goes through rapid musculoskeletal change ending, in some instances, in separation of and damage to the muscles of the pelvic floor and abdominal wall. Publications in the Annual Review of Biomedical Engineering in 2009 and Obstetrics & Gynecology in 2004 note that even in the best-case scenario, the pelvic floor withstands immense tissue strain during a vaginal delivery, with an estimated stretch ratio of 3.26. At the other end of the spectrum are the individuals who experience a tear, an episiotomy or a cesarean section.

Authors of an article published in the European Journal of Obstetrics and Gynecology and Reproductive Biology in 2016 note that during the third trimester of pregnancy, between 24% and 42% of women report distress from prolapse, urinary or colorectal symptoms. According to data published in the European Spine Journal in 2004, at least 45% of women report pelvic girdle or lower lumbar pain during pregnancy, 25% of which is described as serious and 7% of which is described as disabling. And 48% of pregnant women report psychological strain from PFD symptoms, according to research published in the Archives of Gynecology and Obstetrics in 2019. It's also important to remember that symptoms of pelvic floor dysfunction can remain silent until the mother returns to higher levels of fitness and activities, after discharge from the care of an obstetrician.

These situations present the perfect opportunity for physical therapy (PT) intervention. PT is a noninvasive and low-risk intervention to reduce pain and optimize muscular coordination, strength and endurance. PT referrals are common in the sports and orthopedics settings when a muscle is torn or otherwise functioning suboptimally. Additionally, in the acute care setting, physical therapists are routinely called upon to help patients optimize function and safety and reduce hospital readmissions. So we believe that a PT referral should be standard for our postpartum patients as well. These individuals should not need to wait for years before accessing care, including surgery, for pelvic floor-related issues.

How common are PT referrals for postpartum PFD worldwide and within the US?

Referral to pelvic PT during the postpartum phase is already the standard of care in many countries. In an abstract shared at the International Continence Society meeting in 2017, the authors note that patients in France, for instance, automatically receive a prescription for 10 PT visits to rehabilitate their abdominal and pelvic floor muscles after childbirth. In contrast, within the United States, lack of awareness about the benefits associated with early intervention and PT referral for PFD is still fairly common. We need more research to identify the true scope of the problem and shed light on why some individuals are affected and others are not. Those efforts could validate the need for screening and early detection measures and help us develop best practices for treatment and high-quality patient education resources and support.

What are the goals for this type of PT?

During the postpartum phase and beyond, pelvic floor PT (PFPT) treatment plans are designed to help reduce or eliminate PFD symptoms and long-term sequelae that affect patients' quality of life. Our goals include increasing pelvic floor muscle strength and endurance; reducing urinary or fecal incontinence and pelvic organ prolapse; and addressing sexual dysfunction and any other functional impairments, such as lumbopelvic pain, and diastasis rectus abdominis (DRA).

What is the optimal timing for pelvic floor PT?

The first month after childbirth is often called the fourth trimester and is an important period of transition and recovery for the musculoskeletal system. Caring for both a newborn infant and, in some cases, toddlers and other family members can be physically challenging. Often, the movement strategies that mothers adopt during the postpartum phase are suboptimal. Additionally, the American College of Obstetricians and Gynecologists recently acknowledged gaps in postpartum care and updated recommendations to include PT as part of maternal recovery from birth to address urinary and fecal incontinence. PT also should be considered immediately postpartum to address DRA, pelvic organ prolapse and pain.

We believe that providing patients with access to PT 1 to 3 days after delivery, while they are still in the hospital, and again between two and six weeks after they are discharged from the hospital will normalize seeking or receiving pelvic health services for the entirety of the patients' lives. We suspect that fewer visits will be needed overall if care is initiated early. Authors of a 2020 publication in the Journal of Clinical Medicine and a 2016 publication in the Iranian Journal of Medical Sciences suggest that a pelvic floor physical therapy program as prehabilitation prior to surgery for fecal incontinence may improve surgical outcomes.

What components are typically included in Mayo Clinic's approach?

Mayo Clinic's integrated approach to peripartum pelvic healthcare is individualized to the patient's needs and can include any of the following components: exercise, electrical stimulation, biofeedback training, manual therapy and behavioral education.

In the next article in this two-part series, we will share more details about this program, including our approach to provider education, coordination of care and related research efforts.