PROVIDENCE, R.I. – A postpartum perineal clinic staffed by urogynecologists has been established at the University of Michigan to expedite the assessment and treatment of pelvic floor disorders resulting from maternal birth injuries, according to Dr. Cynthia Brincat, who described the clinic in an oral poster presentation at the meeting.
“About 10% of women develop complications associated with childbirth. We are a one-stop location for these women to be seen during a very busy and very stressful time in their lives,” Dr. Brincat said in an interview. “We provide focused, problem-based, short-term therapy. Patients then can go back to their regular providers, often with a care plan that can be carried out in that setting.” Dr. Brincat worked at the clinic as a fellow in female pelvic medicine and reconstructive surgery at the University of Michigan Medical Center, and is now with the University of Wisconsin–Madison.
At the Michigan Healthy Healing After Delivery Program, patients are seen within 2 weeks of requesting an appointment. It offers its services to women with such symptoms as fecal or urinary incontinence, painful or nonhealing episiotomy, anal fissures, third- or fourth-degree lacerations, rectovaginal fistulas, postpartum urinary retention, pelvic organ prolapse, and painful intercourse.
The clinic provides a range of services. “Some of the treatments we provide center around asking the right questions and uncovering what is going on. We do a lot of patient education. Once a patient understands what has happened to her, she can take better care of herself,” said Dr. Brincat. “For example, if she has a third- or fourth-degree laceration, she can understand how important it is to keep her stool consistency soft.” Patients can consult with a PhD nurse continence expert and physical therapists who can develop a pelvic floor muscle-strengthening program or provide advice concerning diet and lifestyle changes to promote healthy living and prevent future incontinence problems. Counseling in the clinic deals with the patient's emotional well-being and fears about future pregnancies.
More focused interventions include cauterization of granulation tissue, application of nitroglycerin paste for anal fissures, trigger-point injections for pain relief, or estrogen application for atrophic vaginal tissue. Biofeedback is commonly used for helping patients visualize the most effective ways to perform pelvic floor muscle contraction exercises. Other services provided include endoanal ultrasound for the assessment of sphincter anatomy and multichannel urodynamics to assess bladder function. MRI studies, performed under approved research protocols, are useful for detailing birth trauma such as injury to the levator ani and can help physicians establish a plan for avoiding injuries with subsequent births. Some patients require surgical management for incontinence, anal sphincter repair, or debridement.
Now in its fourth year, the practice has been steadily growing. Total new patient visits increased 35% from year 1 to year 2 (from 40 to 62) and 7.5% between year 2 and year 3 (62 to 66). “This year we are on track to see 80 new patients,” said Dr. Brincat. The most common presenting problems were follow-up of third-degree lacerations, urinary incontinence, and perineal pain.
Analysis of referral distribution indicated that less than one-third of referrals were from the University of Michigan's in-house generalist practice. Thirty-one percent came from the resident practice, and 41% were referred from family medicine practice, certified nurse-midwife practice, outside physician referrals, and self-referrals.
“We knew we had to build a broad referral base to be successful,” said Dr. Brincat. To accomplish this, the nurse coordinator and staff members undertook direct patient marketing via Web search engines, YouTube videos, podcasts, and distribution of printed patient education materials. Peer-to-peer programs targeted nurses and other obstetric providers. All referrals are cleared through one point of entry, a knowledgeable nurse who can triage patients and serve as an ongoing contact.
Although there was some initial reluctance among generalists to refer patients, that no longer holds true. “Patients often don't see us more than once – our average number of visits is about 1.6,” said Dr. Brincat. Once a primary provider sees that the patient returns to his or her practice, the provider is less reluctant to refer the next patient. In fact, she said, the bond with the primary provider is often strengthened once the patient realizes that the provider values the patient's outcome enough to send the patient for specialized treatment when necessary.
“In the United Kingdom and most European countries, anyone who hasundergone a traumatic birth injury is seen in a follow-up clinic right away. In the United States, that's not the standard of care. What we're trying to do is change that,” said Dr. Brincat. “In general, the assessment and treatment of women with birth injuries is not given enough attention. If this was about professional football players or baseball players, and we said 1 in 10 of them would experience a traumatic injury and not be seen for weeks afterwards, I think the issue would get a lot more attention.”