The Fourth Trimester: Identifying Pelvic Floor Dysfunction

In 2017, the American College of Obstetrics and Gynecology reported [1] on The 4th Trimester Project patient engagement meeting, where new mothers were asked, “what issues are not effectively communicated to women?” Women reported a desire for clinicians to ask questions related to pelvic floor dysfunction, back pain and incontinence. They wanted healthcare providers to open the conversation about these common postpartum problems and to provide resources to treat these symptoms. To help meet this need, there is a movement among physical therapists to provide postpartum women musculoskeletal and pelvic floor screening exams as a standard part of obstetrical care.

Women Lack Information about Postpartum Problems

Women need to be aware of common problems following childbirth. Many women try to return to previous activity levels only to discover that low back pain (LBP), pelvic girdle pain (PGP), urinary or fecal incontinence (UI ,FI), pelvic organ prolapse (POP) or pain with sexual activity limit their function and quality of life. Currently, women may perceive these issues as normal consequences of childbearing and delivery, or be hesitant to start a discussion about incontinence, pelvic pain or sexual dysfunction with their healthcare provider. Unfortunately, this causes musculoskeletal and pelvic floor dysfunctions to go untreated, as women are unaware of the health care resources available. By including pelvic floor questionnaires and screening exams, both during prenatal and postpartum visits, healthcare providers can open the conversation, learn if a woman is having continued pelvic floor problems, and provide a referral for continued specialty care.

Childbirth is a risk factor for multiple pelvic floor dysfunctions and musculoskeletal problems. Urinary Incontinence and Pelvic Girdle pain occur commonly during pregnancy, with up to 77% of pregnant women reporting symptoms when questioned. Depending on the study cited, UI continues to affect 18-60% of women postpartum. Back pain continues in 4-90% of women after childbirth [2].  Sexual penetration pain or dyspareunia is reported by 44.7% women at 3 months postpartum, 43.4% women at 6 months postpartum [3]. Despite these numbers, there is no systematic approach to address common postpartum symptoms, other than the symptoms of depression. There is a need for education prior to giving birth and comprehensive screenings before and after childbirth.

Using Questionnaires to Empower Women with Knowledge

About one-third of women have urinary incontinence and up to one-tenth have fecal incontinence after childbirth [4], yet these issues frequently go untreated. In her 2018 Doctoral Thesis Pelvic Floor Dysfunction in Women: Tackling Barriers [5], Hedwig Neels reviewed the importance of educating women regarding pelvic floor dysfunction. Her work underscores the need for early awareness and education. Neels demonstrated that women of all ages have a limited knowledge of the pelvic floor and its function. Regular screenings with standardized questionnaires will educate women about symptoms and enable earlier identification and referral to providers.

For pelvic floor conditions, the Queensland Female Pelvic Floor Questionnaire [6] assess 4 areas of common symptoms, (bladder, bowel, pelvic support and sexual function) and their impact on daily activities. The questionnaire provides a comprehensive, condition-specific, self-completion format. Screenings should be provided by OBs during pre- and post-natal visits and can also be administered by, PCPs, physical therapists, midwives, doulas and childbirth educators. It is my hope that women are provided these screening questionnaires once during pregnancy, then again on or before their postpartum checkups (See my related article Redefining the Postpartum Visit). Reviewing the findings of the questionnaire decreases the chance of these problems going undiagnosed and encourages women to seek care for their symptoms.

As a pelvic physical therapist with over 30 years of experience treating postpartum women with pelvic floor dysfunction, I want women to know and seek care for common pelvic floor, pelvic girdle or other musculoskeletal symptoms related to childbirth. I also want to increase knowledge of and access to multidisciplinary resources and treatments available. I would like to see women, and those involved in postpartum care, embrace the 4th Trimester as a time to care for women as much as we do for newborns.

For a comprehensive list questionnaires and outcome measures, see the Resources page. If you are a pelvic health therapist interested in continuing education regarding postpartum recovery , please see Kathe’s Teaching page.

  1. Tully, K. P., Stuebe, A. M., & Verbiest, S. B. (2017). The fourth trimester: a critical transition period with unmet maternal health needs. American Journal of Obstetrics & Gynecology, 217(1), 37-41.
  2. Mannion, C. A., Vinturache, A. E., McDonald, S. W., & Tough, S. C. (2015). The Influence of Back Pain and Urinary Incontinence on Daily Tasks of Mothers at 12 Months Postpartum. PLoS ONE, 10(6), e0129615.
  3. McDonald, E. A., Gartland, D., Small, R., & Brown, S. J. (2015). Dyspareunia and childbirth: a prospective cohort study. BJOG: An International Journal of Obstetrics & Gynaecology, 122(5), 672-679.
  4. Woodley, S. J., Boyle, R., Cody, J. D., Mørkved, S., & Hay‐Smith, E. J. C. (2017). Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. The Cochrane Library.
  5. Neels, H. (2018). Pelvic floor dysfunction in women: tackling barriers (Doctoral dissertation, University of Antwerp).
  6. Baessler, K., O’Neill, S. M., Maher, C. F., & Battistutta, D. (2010). A validated self-administered female pelvic floor questionnaire. International urogynecology journal, 21(2), 163-172.

Thank you to Richard Galindo, SPT, University of WA, Dept of Rehabilitation, Division of Physical Therapy for literature review assistance to prepare this article.

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