Do obstetrical providers counsel women about postpartum pelvic floor dysfunction?

Abstract

Objective

To assess prenatal counseling practices of obstetrical providers related to postpartum pelvic floor dysfunction at centers with integrated urogynecology services.

Study Design

A cross-sectional survey was distributed to obstetrical providers through urogynecology colleagues. The survey included questions about level of training as well as counseling practices related to common postpartum pelvic floor symptoms. All statistical tests were two sided, and P values <0.05 were considered statistically significant.

Results

One hundred ninety-two surveys were received; 19 respondents did not perform their own prenatal counseling and were excluded. Among the remaining 173 respondents, 94 (56.3%) of those who answered the question reported never discussing postpartum urinary incontinence, and 73.7% reported never discussing postpartum fecal incontinence during prenatal counseling. Obstetrics and gynecology residents were significantly less likely than attending physicians to report discussing various pelvic floor dysfunction topics in prenatal counseling. Among those who reported not counseling women regarding pelvic floor dysfunction, the most common reason cited was lack of time (39.9%) followed by lack of sufficient information (30.1%).

Conclusion

Prenatal counseling of pelvic floor dysfunction risk is lacking at all levels of obstetrical training. Limitations of time and information are the obstacles most often cited by providers.

INTRODUCTION

An estimated 9.7% of women ages 20–39 in the United States have at least one symptomatic pelvic floor disorder.¹ This is likely a conservative figure, given that these disorders are widely underreported.² Furthermore, the number of affected women is expected to rise as the population ages.

The mechanisms by which pregnancy and childbirth contribute to pelvic floor dysfunction are not completely understood, but several studies have demonstrated that higher parity, operative vaginal delivery and episiotomy may be associated with an increased incidence of pelvic floor disorders.^3–8 During pregnancy, a large proportion of women experience urinary incontinence, and these women are more likely to experience similar problems postpartum. Although the prevalence of incontinence decreases over time during the postpartum period, women with incontinence at 3 months after their delivery are at high risk of long-term symptoms.^9,10 Strategies to minimize episiotomy and operative vaginal delivery aim to mitigate the incidence of pelvic floor damage, and there is some evidence that pelvic floor physical therapy may decrease the incidence of pelvic floor dysfunction and shorten the duration of symptoms.^11–18 Despite the known positive correlation between parity and pelvic floor disorders, specifically urinary incontinence and pelvic organ prolapse, and available effective therapies, such as behavior modification, medication and surgery, it has been noted that obstetrical providers do not routinely discuss these issues with patients.^4,18,19 Furthermore, this topic is often the subject of controversy.

There are limited data available to evaluate the frequency and extent to which obstetrical providers counsel patients regarding the possible effects of pregnancy and childbirth on pelvic floor function, whether obstetrical providers feel that there is adequate literature and knowledge regarding this topic and whether providers consider antepartum or postpartum intervention. We conducted a pilot survey of obstetrical providers at multiple institutions with urogynecology services to determine their prenatal counseling practices related to postpartum pelvic floor dysfunction. We hypothesize that prenatal counseling on pelvic floor disorders is limited, particularly among trainees. If this counseling is limited, we aim to identify areas where intervention can be targeted with the goal being to provide patients information so that they will be more comfortable reporting any PFD to their providers and be aware of treatment options for postpartum PFD such as pelvic floor physical therapy.

MATERIALS AND METHODS

The institutional review board at Mount Auburn Hospital approved this study. From March 1, 2010 through September 1, 2010, we asked urogynecology physicians at geographically diverse academic and community medical centers throughout the United States to distribute a brief questionnaire regarding prenatal counseling practices to all practicing obstetricians within their institution. Physicians from individual sites distributed either paper surveys or a link to an online survey. All survey responses were anonymous.

The survey included baseline demographic information, such as level of practice (e.g. attending, resident) and sub-specialty training. We also queried respondents regarding their general prenatal counseling practices related to common postpartum pelvic floor symptoms. For each question, respondents were asked to report whether they always, sometimes or never discuss a particular symptom or outcome during prenatal visits.

All statistical analyses were performed using SAS 9.2 (SAS Institute Inc., Cary, NC). All tests were two sided, and P values <0.05 were considered statistically significant. Data are presented as proportions; comparisons were made using a Chi-square or Fisher’s exact test, as appropriate.

RESULTS

The participating sites included 28 medical centers (15 academic and 13 community) in 9 states. Eighteen institutions had ACGME residency programs in obstetrics and gynecology and seven had urogynecology fellowship programs. One hundred ninety-two physicians completed questionnaires. Nineteen respondents (9.9%) were excluded from the analysis because they reported that they did not perform their own prenatal counseling. Among the 173 respondents included in the analysis, 49.7% were general obstetrician-gynecologists, 33.5% were obstetrics and gynecology residents, 9.8% were maternal fetal medicine faculty or fellows, and 6.9% were midwives or nurse practitioners. The majority of respondents were female. Respondent characteristics are described in Table I.

Table I.

Respondent characteristics

Characteristic	N (%)
Gender
Female	136 (78.6)
Male	37 (21.4)
Level of practice
General ob-gyn attending physician	86 (49.7)
Ob-gyn resident physician	58 (33.5)
Postgraduate year 1	11 (19.6)
Postgraduate year 2	12 (21.4)
Postgraduate year 3	17 (30.4)
Postgraduate year 4	16 (28.6)
Maternal-fetal medicine attending or fellow	17 (9.8)
Midwife or nurse practitioner	12 (6.9)
Years since residency or training
0 to < 6	28 (24.4)
6 to < 10	21 (18.3)
10 to 20	39 (33.9)
> 20	27 (23.5)

Ob-gyn: obstetrics-gynecology

Nearly half of respondents reported never discussing postpartum stress urinary incontinence or anal sphincter laceration with nulliparous women during prenatal counseling, and the majority reported never discussing postpartum fecal incontinence or dyspareunia. One-third of respondents reported never discussing possible pelvic floor dysfunction as a factor when comparing methods of delivery. A similar proportion reported never recommending antepartum or postpartum pelvic floor physical therapy to nulliparous women. Respondents’ counseling practices for nulliparous women are shown in Table II.

Table II.

Counseling practices for nulliparous women

Pelvic Floor Dysfunction Topic	All Respondents N (%)	Ob-gyn Attending Physicians N (%)	Ob-gyn Resident Physicians N (%)	P*
Stress urinary incontinence				<0.001
Always	9 (5.4)	2 (2.4)	5 (8.8)
Sometimes	64 (38.3)	40 (48.2)	11 (19.3)
Never	94 (56.3)	41 (49.4)	41 (71.9)
Fecal incontinence				0.07
Always	4 (2.4)	2 (2.4)	2 (3.5)
Sometimes	40 (24.0)	23 (27.7)	7 (12.3)
Never	123 (73.7)	58 (69.9)	48 (84.2)
Dyspareunia				0.002
Always	12 (7.2)	5 (6.1)	2 (3.5)
Sometimes	53 (31.9)	34 (41.5)	9 (15.8)
Never	101 (60.8)	43 (52.4)	46 (80.7)
Perineal laceration				0.11
Always	54 (32.3)	24 (28.9)	18 (31.6)
Sometimes	87 (52.1)	51 (61.5)	27 (47.4)
Never	26 (15.6)	8 (9.6)	12 (21.1)
Anal sphincter laceration with vaginal delivery				<0.001
Always	10 (6.0)	4 (4.8)	4 (7.0)
Sometimes	70 (41.9)	45 (54.2)	10 (17.5)
Never	87 (52.1)	34 (41.0)	43 (75.4)
Anal sphincter laceration with instrument delivery				0.006
Always	63 (38.4)	39 (47.0)	13 (23.2)
Sometimes	66 (40.2)	31 (37.4)	24 (42.9)
Never	35 (21.3)	13 (15.7)	19 (33.9)
Pelvic floor dysfunction risk by mode of delivery				0.02
Always	29 (17.5)	20 (24.1)	5 (8.8)
Sometimes	78 (47.0)	41 (49.4)	27 (47.4)
Never	59 (35.5)	22 (26.5)	25 (43.9)
Recommend antepartum or postpartum physical therapy				0.01
Always	32 (19.8)	19 (24.1)	6 (10.5)
Sometimes	71 (43.8)	36 (45.6)	20 (35.1)
Never	59 (36.4)	24 (30.4)	31 (54.4)

Proportions are based on the total number of responses to a given question.

^*Comparison is between attending physicians and resident physicians

Respondents who reported that they did not counsel women on pelvic floor dysfunction were asked to report why they did not do this. The most common reason cited was lack of time (39.9%). This was followed by lack of sufficient information regarding pelvic floor dysfunction (30.1%), the assumption that patients know that pelvic floor dysfunction is part of a normal pregnancy and delivery (14.5%), a perceived low incidence of pelvic floor dysfunction (13.9%) and the concern that patients would elect cesarean delivery if informed of the risks associated with vaginal delivery (7.5%).

For primiparous women, more than half of respondents reported never discussing pelvic floor dysfunction as a possible risk of vaginal birth after cesarean delivery among women who were counseled regarding trial of labor. For women with a history of pelvic floor dysfunction, one-third of respondents reported never discussing with patients the option of a cesarean delivery based on existing pelvic floor symptoms. Similarly, although the majority of providers utilize physical therapy and urogynecology services at least sometimes, approximately one-third reported never referring women with pelvic floor disorders to physical therapy, and 28.6% reported never referring them to a urogynecologist based on their symptoms. Table III shows the reported counseling practices for primiparous women.

Table III.

Counseling practices for primiparous women

Pelvic Floor Dysfunction Topic	All Respondents N (%)	Ob-gyn Attending Physicians N (%)	Ob-gyn Residents Physicians N (%)	P*
Pelvic floor dysfunction as a risk of vaginal birth after cesarean delivery				0.05
Always	17 (10.6)	13 (16.1)	4 (7.3)
Sometimes	47 (29.2)	26 (32.1)	11 (20.0)
Never	97 (60.3)	42 (51.9)	40 (72.7)
Ask about pelvic floor dysfunction from prior delivery				0.37
Always	36 (22.4)	21 (26.6)	10 (17.5)
Sometimes	90 (55.9)	43 (54.4)	32 (56.1)
Never	35 (21.7)	15 (19.0)	15 (26.3)
Recommend cesarean based on prior pelvic floor dysfunction				0.002
Always	4 (2.5)	3 (3.7)	1 (1.9)
Sometimes	109 (67.7)	62 (75.6)	27 (50.0)
Never	48 (29.8)	17 (20.7)	26 (48.2)
Refer women with a history of pelvic floor dysfunction to urogynecology				0.83
Always	19 (11.8)	7 (8.8)	5 (8.9)
Sometimes	96 (59.6)	51 (63.8)	33 (58.0)
Never	46 (28.6)	22 (27.5)	18 (32.1)
Refer women with a history of pelvic floor dysfunction to physical therapy				0.02
Always	23 (14.4)	11 (13.8)	6 (10.7)
Sometimes	87 (54.4)	53 (66.3)	26 (46.4)
Never	50 (31.3)	16 (20.0)	24 (42.9)

Proportions are based on the total number of responses to a given question.

^*Comparison is between attending physicians and resident physicians

As shown in Tables II and III, the prenatal counseling practices of residents differed significantly from those of attending physicians. Compared to attending physicians, residents were less likely to counsel nulliparous women on urinary incontinence, dyspareunia, anal sphincter laceration, and pelvic floor dysfunction risk by mode of delivery (all P<0.02). In addition, residents were less likely to report referring women to pelvic floor physical therapy (P=0.01) and were less likely to discuss the alternative of cesarean delivery for primiparous women with a history of pelvic floor dysfunction (P=0.002).

Male and female respondents provided similar prenatal counseling about most pelvic floor disorders; however, female providers were more likely to never discuss pelvic floor dysfunction as a potential risk factor after vaginal birth after cesarean delivery (65.1% versus 42.9%, P=0.02). Prenatal counseling on pelvic floor dysfunction did not differ by resident year of training (P>0.06).

DISCUSSION

Despite the prevalence of pelvic floor symptoms after delivery^{3, 4, 10}, a substantial proportion of obstetrical providers surveyed did not offer prenatal counseling on common pelvic floor symptoms such as urinary and fecal incontinence and dyspareunia. With appropriate resources, such as counseling from obstetric providers and access to treatment options, we believe women will seek treatment earlier, not waiting until symptoms become severe, and therefore likely lessen the impact of these symptoms on their quality of life. In our study, the majority of providers reported never counseling their prenatal patients regarding at least one of several potential risks to the pelvic floor, such as dyspareunia and urinary and fecal incontinence, despite growing evidence that pregnancy and childbirth are risk factors for pelvic floor disorders that can significantly impact quality of life and are amenable to treatment.^{4, 19} Similarly, approximately one-third of providers reported never discussing pelvic floor dysfunction as a factor when considering different methods of delivery. A similar proportion reported never recommending pelvic floor physical therapy, which has been shown to improve recovery time and symptoms of postpartum pelvic floor dysfunction.^{15, 16, 18} However, it is not known whether all respondents had these resources available to them.

The most common reason cited for lack of counseling regarding pelvic floor dysfunction was time. This is not surprising given pressure for providers to see increasing numbers of patients. Lack of sufficient education regarding pelvic floor dysfunction was another commonly cited reason. This lack of time and educational resources may be the reason that residents were less likely than attending physicians to discuss pelvic floor dysfunction during prenatal counseling. Expanding resident education regarding pelvic floor disorders early in residency, as well as improving patient educational materials may help to improve counseling during visits with limited time. Additionally, patients who experience symptoms may be able to implement simple behavioral therapies or pursue a course of physical therapy before or after delivery.

This study has several limitations that may limit the generalizability of our findings. We used a convenience sample of institutions where we had contacts to assist with questionnaire distribution, which limited the geographic representation of our sample. As a result of this approach, we do not know the number of surveys distributed nor do we have any data on the non-responders. Therefore, we are unable to calculate a response rate and are unclear whether the counseling practices of non-responders differ from those of the respondents.

In addition, we surveyed a relatively small number of institutions and only included institutions with urogynecologists. We started with this convenience sample theorizing that any urogynecologic presence might increase the likelihood of awareness and exposure to pelvic floor disorders and the variety of interventions. However, we did not ask about the number of urogynecologists at each institution and therefore could not account for variability in counseling practices that may be related to the size of the urogynecology practice. An additional limitation is that we had small sample sizes within strata of gender and resident postgraduate year; thus, we had limited power to detect differences when comparing groups. Regardless, the low level of discussion among our respondents regarding pelvic floor dysfunction suggests a need for greater patient and provider education and resources to facilitate counseling. To better understand these issues and counseling patterns regarding pelvic floor dysfunction nationally, a larger survey among a more representative sample of institutions would be required. Additional study of how knowledge of pelvic floor dysfunction and patient counseling may be incorporated into practice patterns related to pelvic floor protection on labor and delivery units would also be valuable in understanding how to best to promote effective interventions and early treatment to minimize postpartum pelvic floor dysfunction.

Prenatal counseling regarding pelvic floor dysfunction risk is not fully addressed at all levels of obstetrical training, even in centers with integrated urogynecology services in the obstetrics and gynecology departments. Limitations of time and information are the most commonly cited obstacles. Although it is unlikely that providers will be able to increase the length of prenatal visits, it is possible to provide targeted educational resources to both patients and providers to aid in understanding the symptoms of pelvic floor dysfunction, help direct earlier treatments as well as potentially aid in decision-making during peripartum care. Resident education is an area to effectively incorporate knowledge of pelvic floor dysfunction, as well as potentially modifiable risk factors, which may help integrate counseling on pelvic floor symptoms into obstetric practice.

Possible next steps include developing and evaluating educational resources for patients and providers. The initial step should include examining the optimal time and manner of introducing patients to these resources, including the ideal setting for prenatal pelvic floor counseling, as well as the timing and frequency of counseling. These resources should then be prospectively evaluated to determine whether these interventions influence women to report symptoms and seek treatment earlier or more frequently than previously.

Although our limited understanding of the mechanism by which pregnancy and childbirth lead to pelvic floor dysfunction restricts our ability to recommend a particular mode of delivery for a patient, patient awareness and earlier treatment may positively affect outcomes regardless of mode of delivery. Prenatal counseling on postpartum pelvic floor disorders may allow patients to anticipate potential symptoms and to have the option of accessing resources, such as pelvic floor physical therapy. Patients may also potentially feel more comfortable discussing symptoms with their providers. The treatment options for women with pelvic floor disorders are rapidly growing; however, unless women suffering from these disorders are identified and offered treatment, the majority of women with these disorders will continue to experience symptoms in silence.^{1, 2} For this reason, we believe that incorporating counseling regarding risk factors and symptoms of pelvic floor dysfunction during the peripartum period will help women suffering from pelvic floor disorders obtain appropriate and timely treatment, as well as allow women the opportunity to address these issues with their providers both before and after delivery.

Synopsis.

Prenatal counseling regarding the risk of pelvic floor dysfunction is incomplete at all levels of obstetrical training, even in centers with active urogynecology services.