For many women who have suffered from physical trauma as a result of childbirth, and who are struggling to cope, is it vital that healthcare providers acknowledge the level of distress that these women are experiencing. While in some instances the physical symptoms will resolve with time, in some cases of trauma that will not be the case.
This section will deal with the practicalities of identifying those cases where there has been permanent damage to the pelvic floor structures. For these women, education on what, and possibly why this occurred, as early as possible in the postpartum period, will be most effective. It is really important that as healthcare providers – women are listened to and their concerns acknowledged. It is not enough to just go on the notes from the delivery, as often these will not reflect the cause for concern and may be seemingly normal.
What we mean by ‘physical trauma’ is major, permanent damage to pelvic floor structures. There are some forms of trauma we can’t see or easily diagnose, such as damage to nerves and fascial structures. Other forms of trauma are so obvious that women sometimes diagnose themselves, such as major levator trauma or ‘avulsion’. This is often overlooked in delivery suite however, even in the presence of a large vaginal tear. Proper diagnosis is possible by palpation/ physical examination, but ought to be confirmed on ultrasound imaging. The other main form of major trauma, anal sphincter tears, are often diagnosed immediately after childbirth, but more than half get missed and may later be picked up by ultrasound. Such tears of the anal sphincter are not easily palpable unless they are severe.
There is an urgent need for midwives, GPs, physiotherapists, gynaecologists, urogynaecologists and imaging specialists to become more knowledgeable in this field. In this section we provide information on how to assess pelvic organ support and the levator ani (pelvic floor) muscle properly.
Practice Points for Health Professionals
A good history from the patient’s perspective as well as from the delivery notes is essential. Delivery note ‘red flags’ include:
Macrosomia (big baby)
Age >= 35 at birth
Urinary retention (unable to wee)
Long second stage
Precipitous second stage
Any of these red flags should alert you to the possibility of pelvic floor muscle trauma.
Other questions specific for pelvic floor trauma (and in addition to standard medical history)
Ask about symptoms of prolapse: Most telling symptom is the feeling of a ‘lump’ or bulge or a dragging sensation in the vagina. May be more pronounced at the end of the day, when lifting baby or trying to return to any sort of exercise. This symptom is highly associated with likelihood of trauma (avulsion) to the levator ani muscle.
Ask about issues with bladder emptying – is there a feeling of incomplete emptying, difficulty in starting urination, – again indicative of anterior wall prolapse
Incontinence, (any involuntary urinary leakage). The relationship between incontinence and avulsion is not as clear, however it is important to determine if the incontinence is new, was it present during pregnancy, (stress) , how often, how much, any nocturia?
Ask about sexual function – has there been intercourse? any pain, bleeding, urinary leakage? How does the patient feel about the resumption (or not) of sexual intercourse.
Contraceptive use, breastfeeding? – this can contribute to vaginal dryness
This information may be useful for general practitioners, physiotherapists and gynaecologists.
ONE: There are six main components to a clinical examination to diagnose pelvic floor trauma in women following birth:
Inspection of the urogenital area, look for tenderness, swelling, signs of infection (if there has been perineal tears) any asymmetry/ distortion/ of the perineal area.
TWO: Clinical stress test or CST: ask the patient to cough and Valsalva while watching the external meatus for urine loss.
THREE: After voiding: POP-Q prolapse quantification. Maximal descent of anterior, central and posterior compartments are determined against the hymenal remnant on maximal Valsalva of at least six seconds’ duration. Try and ascertain that the patient is not contracting the levator (evident as cranial displacement of the anus and dorsal displacement of the clitoris. Aa (stage 1) Ba or Bp of up to -1.5 is normal, but a (stage 1) uterine descent to -4 clearly is not. We consider Aa and Ap superfluous. TVL is measured on maximal Valsalva. Also watch the anus for signs of rectal prolapse, and the perineum for excessive perineal descent and asymmetry indicating avulsion.
FOUR: Bimanual examination to exclude pelvic masses, stool and urinary retention.
FIVE: Palpation of the levator ani for thinning, avulsion and Oxford grading (0-5). Resting tone may also be assessed on a scale from 0-5. One should start by palpating the urethra, then the anterior fornix bilaterally, ie. the gap between the urethra and levator ani. Normally this just fits one finger. The finger should then be placed on the inferior pubic ramus lateral to the urethra and moved laterally while asking the patient to perform a pelvic floor muscle contraction. A full avulsion is diagnosed if there is no contractile tissue palpated on the inferior pubic ramus or the body of the os pubis itself. Make sure that you don’t mistake the bulbocavernosus muscles (which are lower and not directly connected to the inferior pubic ramus) for the levator.
SIX: Digital rectal examination for resting tone of anal canal and external sphincter and squeeze pressure. Sometimes it is possible to palpate scarring and EAS defects. Then ask patient to Valsalva while palpating the anterior wall of the rectal ampulla for rectocele. In a patient with true rectocele the superior margin of the rectovaginal septum can usually be palpated as a well- defined discontinuity. Finally, check whether anything descends towards the palpating fingertip on Valsalva. If the finger is pushed back by tissue (rather than stool) there likely is an intussuception.