Perineal Tears: Discussions with a Urogynecologist

Urogynecoloist Dr. Roxana Geoffrion and Melissa Dessaulles, BScPT, BScKin, Pelvic Health discuss OASIS (obstetrical anal sphincter injuries), risk factors and statistics around perineal tearing, management techniques and more.

Resources:

• bepelvichealthaware.ca
• Instagram: BePelvicHealthAware

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Transcript

[00:00:00] This episode is a collaboration between Melissa Dessaulles of Mommy Berries Physiotherapy and the Pelvic Floor project.

[00:00:06]

[00:00:56] Melissa Dessaulles: If you have experienced a perineal tear during [00:01:00] childbirth, or are currently pregnant and nervous about having a perineal tear during childbirth, or maybe you assist in delivering babies, either way, this episode was recorded just for you.

[00:01:14] My guest today is Dr. Roxanna Geoffrion, a urogynecologist based in Vancouver, BC. She and her amazing team have started a campaign called Be Pelvic Health Aware. The mission is twofold to bring evidence and current clinical practice guideline to the forefront, as well as bring awareness to topics that can improve birth outcomes.

[00:01:37] In this episode, we will talk about the classification of perineal tears, the types of episiotomy, and when each is recommended to be used, the statistics on perineal tearing, how you can be proactive to minimize chance of tearing, what you can expect for management if you do experience a tear. The importance of [00:02:00] knowing the details of your birth and what questions you should be asking of your care provider.

[00:02:07] Of course, we'll also cover how pelvic health physiotherapists fit into the equation. I'm confident you'll learn a lot in this episode and that you know others who can benefit from this information as well. So please do both Dr. Geoffrion and I a favour and help us spread the word about perineal tearing and obstetrical anal sphincter injuries.

[00:02:30] Let's get into the details. Alright, I'm really looking forward to this discussion because I know this is a hot topic and I'm gonna get you, Roxanne, to introduce yourself in a minute. But let me just say a little bit about how I know you first and how I was introduced to you. I've been doing this podcast for a while and I was lucky to have a conversation with one of the physios Trish Gibson recently about exercise postpartum, and she mentioned that you would be a great person for me to chat with just because of your [00:03:00] campaign, Be Pelvic Health Aware, and I really wanna get into that a little bit more. But just for the listeners that are tuning in today, Dr. Geoffrion, Roxanne she's told me to call her, is a urogyn in Vancouver practicing, right? Correct. Correct. And she is here, we're gonna talk a little bit about perineal tearing during childbirth. And a couple of weeks ago, I had an episode come out with a patient advocate who gave her account and experience for everyone, and I thought this would be a great place to follow up with just another side of the story. Thank you so much for being here, and I would love for you to tell everyone a little bit more about yourself.

[00:03:38] Dr. Roxana Geoffrion: Thank you so much, Melissa and I wanted to start by saying thank you for all the awareness you raised on this topic. It's a sensitive topic and it's difficult for women to find the correct information online. And I think what you do is great. I was introduced to you through Trish, like you said, Trish Gibson is a pelvic physiotherapist in Vancouver that works with us on the campaign [00:04:00] along with Adrian Sim, our colleague from Pelvic Physiotherapy. I am a urogynecologist at St. Paul's Hospital. It's called a Center for Pelvic Floor. I work with a group of like-minded individuals who are interested in pelvic floor health. I am trained as an obstetrician gynecologist. I went through residency in OBGYN and then I subspecialized in female pelvic medicine and reconstructive surgery. So now I devote 95% of my time to women with pelvic floor disorders. And referrals come from a variety of sources, family, doctors, obstetricians, gynecologists even pelvic physiotherapists and so on. The women I see are all have some degree of pelvic floor disorder, such as leaking of urine, leaking of stool, pelvic organ prolapse. Lately over the past five years or so, I've started getting a few more referrals for prevention consults. So meaning some women [00:05:00] come in and say, Hey what is all this? And how can I prevent things from happening? Or I've had a bad childbirth experience and now I want to be pregnant again. What do you suggest I do to minimize my chance of having another bad tear or another bad experience?

[00:05:16] So part of it is that, the allied health professionals in my clinic, such as nurse continence advisors, will help us with pessary fittings. So pessaries are devices that are used for urinary incontinence or pelvic organ prolapse. And yeah, so we it, half of it is conservative and half of it is surgical. There are lots of options for women. But you know, I'm trying with my campaign to shift the focus from just treatment to also prevention.

[00:05:45] Melissa Dessaulles: Amazing. I think this is, this experience of this podcast has helped me even just learn about some of the resources out there in our own province. And I think that that's, isn't that one of the kind of maybe downfalls, we have an amazing healthcare [00:06:00] system, obviously, but one of the downfalls is that we are very reactive in our care and I think that so much of that could go differently, right? Like you said, just being a little bit more proactive or preventative in our care. I wanna hear more about your campaign, but I thought it might set the stage first to go through our topic, because then I think people will know where to find more once they learn a little bit about our topic. I thought, as I mentioned, talking about perineal tearing and really breaking it down so that the people listening can understand. I picture the average pregnant person coming in to see me, and I'm starting to see way more because of some of this information. People coming in saying, I really wanna be proactive. I wanna understand my body. And one of their main fears I think, is tearing during childbirth. That is a huge fear that almost every client I think has. And can you talk first of all, cuz I, it's very, I always tell them you're pretty normal if you experience some tearing. When I [00:07:00] explain the anatomy to them of the pelvic floor and that, you know, a baby has to come out of quite a small hole in muscle, and that muscle has to stretch big time, more than it's ever stretched, especially if it's your first baby, obviously. And it would be very common that you have some tearing. And I wonder if you could talk a little bit about the statistics, if you have those off the top of your head. You know, what are some of the statistics out there as far as how common it is to have a perineal tear?

[00:07:28] Dr. Roxana Geoffrion: Sure. Yeah. You know, first off, there are certain adaptations in pregnancy that help us deliver. You know, the hormones of pregnancy, the increased vascularity of the area, so more blood vessels, you know, for good oxygen to the baby. All of these things help to stretch. So it's not like you're trying to pass a baby from the non pregnancy to pregnancy in one day, you have nine months to adapt. And and you know, pelvic floor adapts as well. And you know, women have a great capacity to heal from [00:08:00] tearing much more so than a, any non-pregnant woman. You know, just to give you an idea, a woman in one pregnancy produces, you know, more estrogen than a woman in her whole lifetime, if not pregnant. That's, that counts for something when it comes to healing. In terms of statistics of tearing, I would say it's about half, half roughly. You know, half of women have no tears and half of women have some degree of tearing, and that's with the first child. It's it changes after multiple births because the area is a little bit more stretched out. Now, what women need to really pay attention to is the more severe types of perineal tear. So what we in medicine call third or fourth degree tears. That means tears that don't just include the vaginal skin or the small muscles under the vagina, but also the large muscle that controls continents of stool and gas. And those tears are, or third or fourth degree tears happen, probably documented about one out of 10 women who give [00:09:00] birth to their first child. But we know from research that they're underdiagnosed, meaning they're not picked up often enough. So it's when they're missed that women don't get the right treatment and care to prevent, you know, pelvic floor disorders later in life. So we know that when a woman has had a severe perineal tear she has a confluence of risk factors that, you know, such as a larger baby or perhaps you know, being a little bit older when she first delivers, that will predispose her to having more problems as she ages. So I dunno if that answered your question.

[00:09:32] Melissa Dessaulles: Absolutely. I think that, I loved how you started the answer with we're meant to we're meant to have a baby because I think you're right. It, that question that they have, what can I do to prevent tearing always comes with a; what do I have to do to make su make sure this doesn't happen? And I think just right away them understanding your body knows how to, I feel like I repeat this over the, over and over, your body knows how to have a baby. Just learn how to facilitate that. And I think that, like you [00:10:00] said, we are meant to be able to stretch. We can do it. But that sometimes it's just like any injury or any event that we have in our life. Like sometimes the body, you know, has a little injury that it incurs. And like you said, our body knows how to heal from that as well. And I think that just understanding it all is so helpful. Can you talk about, you mentioned really quickly some of the risk factors, like the size of the baby and maybe the age of the mom, because I know that our tissue and our collagen is different as we age. Are there any other specific risk factors that women might want to be thinking about, when it comes to tearing?

Risk Factors

[00:10:37] Dr. Roxana Geoffrion: Definitely. And you know, we always divide risks into mom's risks and baby risks. And maternal risk factors that increase the risk of severe perineal tearing might include having a pregnancy after age 30, being diabetic during the pregnancy but also outside the pregnancy, and having poor sugar, [00:11:00] glucose control, having certain ethnicities such as Indian or Filipino you know, having had previous severe perineal tear and now having a second pregnancy. Things that are related to the labor itself, such as a very long labor or or needing some sort of episiotomy or an epidural. You know, things like not having enough support of the baby's head at birth. And then the baby risk factors would include something like a very large baby. Large in terms of pelvic floor health are over is, would be over four kilograms or 8.8 pounds. And being born in a position that's conducive to tearing, such as, you know, so the optimal position of the baby's head for birth would be facing down. So if the healthcare provider caring for women laboring feels that the baby is face up or some other position that may be a risk factor for having a worse peral tear. The other big risk factor would be the use of assistive devices such as forceps [00:12:00] and or a vacuum or sometimes both need to be used. So those are the main risk factors I would say.

[00:12:07] Melissa Dessaulles: While we're kind of talking about episiotomy, can you talk a little bit about that? I have, I feel like I've heard a couple things lately, one that you know, maybe some of the protocols ask for less episiotomy, but I've also heard that tissues can sometimes heal better if you do an episiotomy versus natural tearing. Would you speak to that a little bit?

Episiotomy

[00:12:30] Dr. Roxana Geoffrion: Yeah. There's a lot of evidence about episiotomy and so there are certain types. First of all, there are certain types of episiotomies that put you more at risk for severe peroneal tearing. And so you should definitely know what kind of episiotomy is being offered to you. So episiotomy is a cut in the perineum, so between the vaginal opening and the anal opening, and it can be done vertically, so from vagina to anus in a vertical line, or it can be done more optimally at a lateral angle. So you want [00:13:00] to start in the midline of the vagina, but then end your epi episiotomy very lateral to the anal opening to spare that donut muscle around the anal opening that maintains continence of stool and gas. So the objective here is to minimize the tear in that round circular donut muscle. And so there are two strategies for episiotomy. One is called restrictive means you only use an episiotomy if absolutely needed. And the other one is called liberal, where you do an episiotomy and everyone to speed up the baby's delivery. And it was also done in the past to prevent, you know, to have a more controlled type of tear in the perineum. Right now our guidelines our best practice clinical care guidelines tell us to practice medial, lateral episiotomy and restrictive use. Meaning only use it if absolutely necessary and cut at a medial [00:14:00] lateral angle. And there are certain clinical scenarios where an episiotomy will be used in more than others. For example, with a foreceps delivery. Because a lot of times with forceps, the tears tend to be more severe and in all directions, and there's less control over tearing within the muscle of the anus. What we do sometimes with forceps or all the time with forceps is actually perform a medial lateral episiotomy to allow for more space. But for a woman whose labor is progressing well and who you know, the there's no concern about the baby's heart rate and everything is going well, then there is no need for an episiotomy.

[00:14:42] Melissa Dessaulles: Okay. Talk to me about, so let's say you know, whether they have a tear or an a episiotomy, can you explain what happens after baby comes out? Which ones need to be sutured? Maybe what does that look like?

Degrees of Tearing

[00:14:57] Dr. Roxana Geoffrion: Yeah. There are degrees of tearing. Every [00:15:00] woman should know what kind of tear they had, and it's very simple to remember. I know things are very hectic with during birth, but anybody can remember one you know, a number. So the degrees of tearing are from one to four, so you need to know what number you had? Was it? Well, zeros no tear, I guess. But one would be a very minimal tear within the skin of the vagina, and sometimes that doesn't really need to be repaired. Two would be in a little bit deeper involving the small muscles under the vaginal skin. Three would be within that donut muscle, and four would be going all the way into the skin of the rectum. So going all the way down to the anal opening. And what happens with those is that they need to be repaired, right? And with that, there are certain caveats. You know, you have to have proper lighting to repair these properly. You have to be adequately trained. The laboring woman has to have enough anesthesia on board so she's not uncomfortable in moving, you know? And so all of these factors need to be optimal to get a proper tear repair. And so [00:16:00] these are repaired, and then what we do is we try to ensure that a pain control is optimal. That we prevent constipation using laxatives and we make sure that the woman who gave birth can actually urinate normally. You know, there's a pretty high incidence of retention of urine with all the pain and the swelling associated. The other thing is if women prefer to have a home birth, for example, or deliver in a center where their maternity healthcare provider is not trained to perform these cares. What needs to happen is they need to be transferred to a center where they can actually have this done. So think of it as any severe injury that needs repair. And you know what? These repairs, we know that we can wait up to 12 hours after delivery. With some antibiotics on board to prevent infection and making sure that nothing is bleeding terribly. We can certainly transfer a woman who has had this tear from home or from a smaller community into a center where she can have a proper repair performed with adequate lighting, adequate anesthesia, and somebody who knows how to repair these.[00:17:00]

[00:17:00] Melissa Dessaulles: And do you, when you say, do you mean the third and fourth degree tears when you say because... correct. Cause generally it it wouldn't need to like a midwife or your OB would be able to repair like the second degree tears.

[00:17:13] Dr. Roxana Geoffrion: Yes. Yeah. Okay. Most midwives and all obstetricians can repair secondary repairs. All obstetricians can repair any type of tear.

[00:17:22] Melissa Dessaulles: And when you say that, cuz obviously it's not cl, it's not exactly a certain line on the perineum that dictates second, third, or fourth degree tear. And I'm, and I know that's why a, a lot of them go undetected. What would you say then, what makes maybe the third or fourth degree tears go undetected? Is it that it's not obvious that it's going into that rectal tissue, or how would someone listening, maybe if they're unsure, are there certain things you need to do to check that?

[00:17:50] Dr. Roxana Geoffrion: Yes. So that's a fantastic question and I hope everybody's listening to this answer. So really we know that rarely in less than 1% of cases, but rarely, but it [00:18:00] does happen. You can actually have tear of that donut muscle behind an intact perineum. So even if you have no visible tear, you can actually have a tear of the anal sphincter muscle that controls continents of stool and gas. And so the only real way to detect an injury of this muscle is to have a rectal examination performed. And unfortunately, this is not something that is routinely done right after childbirth in all women. And our clinical care guidelines do say that this needs to be routine practice. And having a rectal exam is of crucial importance to assess the, the tone of the muscle and also any defects within the body of the muscle. And if any such defects exist, then we know that the best chance of a woman having a proper repair of this muscle is to have it done right away rather than wait and have it done while breastfeeding or after [00:19:00] three deliveries. That's the best chance for having a proper repair is, or a properly detected injury would be a rectal exam. And the best chance to have a good repair is right at that time not wait and delay repair.

[00:19:16] Melissa Dessaulles: And would you say then too, that it's only kind of those third and fourth degree tears that need to be, because I always recommend think like a stool softener, but would you say it's only kind of those third and fourth that maybe you say go home and use a laxative, but also that would be given the antibiotics?

[00:19:34] Dr. Roxana Geoffrion: Yes, generally. So third and right, so third and fourth degree tears. The guidelines say to use intravenous antibiotics to prevent infection, as well as a stool, a laxative, I should say. Not necessarily a stool softener. Cause those don't work very well. The guidelines say lactulose, which is an osmotic product, meaning what it does is it absorbs water into the stools, so it's easier to pass the stools. It's softer stools. The common [00:20:00] stool softeners, such as Colace, for example, are not great. So we recommend using something like Lactulose or Peg to actually make stools softer and easier to pass.

Proactive Prevention

[00:20:10] Melissa Dessaulles: Awesome. I wanna talk a little bit about how to be proactive. So I love that you're starting to get some of these referrals and I would love to talk a little bit about some of the things that I do as a physio, but I also want to know first what's your approach, or what kinds of things would you teach or would you suggest.

[00:20:30] Dr. Roxana Geoffrion: Yeah. So that's very individual, right? Because, so somebody who might get a consultation to talk about prevention. What we normally do is we closely look at things such as the patient's age and her individual risk factors or family history of pelvic floor disorders, how many children she wants in her life, and how many, you know, how many pregnancies, how many deliveries. That's also very important for counseling. If she's given birth, has she had a bad perineal tear? And all these things come into play. I would say that there are [00:21:00] certain things that all women can do. Performing pelvic floor muscle exercises and learning those on an intact pelvic floor, meaning the women need to learn how to do kegels when they're young. So it should be introduced in schools for teenagers along with sexual education classes. You know, how to perform pelvic floor muscle exercises because it's much harder to learn once you have a damaged pelvic floor. So starting out with knowing how to do your kegs correctly, squeezing and relaxing and doing those throughout pregnancy and postpartum as well. The other things that can also help are, maintaining a healthy weight gain during the pregnancy and also doing certain things during labor such as warm compresses to the perineum, stretching massage of the perineal area while in labor. Things like slowing down the baby's head at delivery have also been shown to help prevent severe perineal tears. And there are other sort of lifestyle factors such as, you know, avoiding [00:22:00] longstanding constipation or downward pressure on the pelvic floor. Certain activities, certain sports you know, a typical one would be trampoline jumping or with repetitive downward strain on the pelvic floor. Those could also be protective.

[00:22:13] Melissa Dessaulles: And I'm gonna talk with in an upcoming episode with another gynecologist about the decision to have a C-section. And I think, I'm sure that comes up sometimes in your conversations. I think there's a lot of negative stigma around C-sections, but understanding all of this, because these women, and this is, came from the episode I did with the patient advocate. The women that have these third and fourth degree tears can be affected for the rest of their life with very embarrassing symptoms. And so I think just understanding, you know, what could come of this, knowing that you can recover, but some people don't fully recover. And so I think that you being able to weigh your pros and cons. And I think, I'm sure that comes up sometimes and I'm, I look forward to going into that in more detail with an upcoming episode. I think just given some of the risk [00:23:00] factors, sometimes women might make the choice to elect to have a c-section for some of those reasons.

[00:23:05] Dr. Roxana Geoffrion: For sure.

[00:23:05] Melissa Dessaulles: I would love to be able to just add a little bit about cuz I, I love all of the suggestions that you have for being proactive. And then as a physio, some of the things that, that I would consider, you know, someone comes in and the very first place I always start is just the anatomy. Just helping them understand, I always say you, you have control of the whole. Um, and just them understanding that even though the pelvic floor muscles are very automatic and we're not used to thinking about them, we actually do have quite a bit of control over them. So just learning, like you said, what it feels like to tighten those muscles, what it feels like to relax those muscles. What does pain normally do to us? It tightens our muscles, but understanding, how to work with your nervous system and visuals and images to help, and breathing strategies to help think about length in those muscles. Also just thinking about that the pelvic floor muscles attach inside the pelvis, and you've mentioned that throughout pregnancy our [00:24:00] pelvis lends to being able to open more and knowing how to use, you know, that different positions can be very helpful for opening the pelvic inlet or the pelvic outlet. And you learning to work with your body, as I say, to kind of let the baby out, easier understanding how to push with different ways, and how holding your breath with a Valsalva, it feels very different than, pushing out with your breath and again, just being able to feel in control. And I think that, I find that clinically, there's a lot of satisfaction I think sometimes. I don't have any direct correlation right now between that and what it, what changes as tearing statistics, but you hear a lot of birth satisfaction when it, when people feel they have control of the process a little bit.

[00:24:53] Dr. Roxana Geoffrion: But the thing is, the thing about control is you know, I think, I don't, I'm not sure everybody understands what that necessarily means, because I [00:25:00] hear this all the time. You know, I had a great birth, I just went in and I just do, and like every, everything was like five minutes and I had two contractions and it just, exploded out and you know, it, everything was fine. I had no tear, but now I have, you know, three pelvic floor disorders. Why did that happen?

[00:25:15] And so I think during labor, we've looked into, okay, what position is best or what, you know, what, is there something about the position of the laboring and delivering woman that can be better for the pelvic floor. And really the issue is about, for us, for me, control means, you know, somebody can actually be there to squeeze your perineum and make sure that the delivery of the baby's head is controlled, meaning slow and steady as opposed to some explosive process because that's when the tearing happens. So it's not necessarily better to have a fantastically rapid birth, that's not necessarily better. That's when, you know, tears can go misdiagnosed. They can be more severe as well. And that's probably somebody who is, you know, there's too much stretch there [00:26:00] already. You know, maybe somebody who needs to work extra hard at getting that new pelvic floor muscle tone back after birth.

[00:26:06] Melissa Dessaulles: Absolutely. We've already talked a little bit now about the importance of asking what kind of tear you had. I find that a lot of patients come in after and I'll say, oh, how did your birth, tell me about your birth. Did you have any tearing? What kinds of symptoms are you experiencing? And a lot of women sit there and say, geez, I don't know. I have no, they didn't tell me. And I can imagine that as maybe the birth attendant there, that you don't necessarily wanna say, oh, it was bad. Because they're going through a lot. I wonder if you could speak a little bit to, obviously I think it's important for the patient themselves to ask, I think that I, we can't put everything on the healthcare provider, but is there, is that in the recommendations? Are women supposed to be told?

[00:26:52] Dr. Roxana Geoffrion: Yes. So it's in our official clinical care best practice guidelines from our National Society, the Society of OB/GYN of Canada,[00:27:00] the word disclose is in there. So one of their recommendations is you need to disclose to the women who just gave birth, what degree of tearing she had, and again, for the women, there are two things you need to ask. Did you do a rectal exam? And what degree of tearing did I have after you did my rectal exam? And you know, they need to remember what degree of tearing they had. We know that women after a third or fourth degree tear have way more symptoms, even with proper repairs. So we know that, you know, a third of women who have a third degree tear will have some degree of anal incontinence, either stool or gas. And half of those who have a fourth degree tear, so through and through will have some degree of anal incontinence. So it's very important to understand what degree of tear they may have had because that changes things for the next birth. Counseling women about future childbirth as well as a referral to pelvic physiotherapy or even a self-referral [00:28:00] to pelvic physiotherapy if the healthcare provider didn't think of it.

[00:28:03] The other thing that happens is women see their healthcare provider, at least their obstetrician or family doctor, I'm not too sure about mid midwifery, but they see them only once at six weeks postpartum. And you know, there's probably not enough time to go into great detail at that particular visit. So women need to be proactive, need to know what kind of tear they had, if they was properly diagnosed, and certainly engage in conversations with their healthcare provider even briefly at that six week visit postpartum

[00:28:32] Melissa Dessaulles: In the guidelines, does it recommend referral to physiotherapy?

[00:28:38] Dr. Roxana Geoffrion: Not at the moment. So that's the big question we, we have. But you know, the problem with research in this area, it's compounded by the fact that women often don't know what kind of tear they had. We're trying to do these sort of retrospective research studies where we look back and see, okay, well what kind of degree of tearing have you had? And should, who should we refer to physiotherapy? So there's active research in this area now, but it's hard to [00:29:00] determine what exactly should warrant referral to physiotherapy. It's easy in cases of the worst case scenario, so a really bad tear or symptoms that's six weeks or you know, some sort of symptomatic incontinence or symptomatic leak of stool or frank prolapse.

[00:29:17] Tho those cases are easy. Okay? Yes, we need to refer to pelvic physiotherapy to help strengthen the pelvic floor and so on. But there are certain gray areas where it's left to the preference of the healthcare provider and the patient if they are referred or not. And and unfortunately, as you know, pelvic physiotherapy is not funded by public healthcare and women have a lot of trouble affording some of these treatments, unfortunately. .

[00:29:44] Melissa Dessaulles: Absolutely. And it's funny though cuz don't you think cuz this is a musculo skeletal injury and as physios like, that's kind of our expertise is musculoskeletal injuries. And if you think about if someone's on a sports field and has a like a muscle tear, I think everybody kind of knows you need therapy for that [00:30:00] and you would know that you don't even necessarily need to know the grade of tear to know that you need rehab and because you would expect that you wouldn't return to full function. And it's actually no different than what you just said.

[00:30:12] But I think that there's just so much mystery with all of this. There's so much I don't know. Yeah. There's a lack of information and there's just a lack of connection, I think, between the being muscles down there and those muscles having functions, right? . So I agree. I think it would be really nice to see some change eventually, to be a little bit more proactive. And I think that it starts here, right? We have conversations and then people can listen to this and decide for themselves whether it's worth it for them to pay for the services. All we can do is talk about it, right now. Okay. Absolutely. I guess then I wanna, one, I wanna talk a little bit about your campaign, but before we get there, maybe if we just think about wrapping up some of the advice we have for listeners. So I think we've talked about obviously advocate for yourself, consider having a proactive approach, you know, you are [00:31:00] part of the decision making process throughout your birth. And you can ask questions about what type of episiotomy you're suggesting or you know, what questions to ask postpartum of your care provider, like you just mentioned. What type of tear did I have and did I have an episiotomy and did you do a rectal exam. But also too paying attention to symptoms at home, and I wonder if there's, because like you said, there's only one planned exam for you or one planned appointment for you at six weeks post, is there anything in the meantime then that women should be watching for? Obviously, you know, we've talked about you, these women can expect that they're gonna be incontinent, so I think, I'm guessing that over time we would expect that they improve, right? So if your symptoms are not improving or maybe they're worsening anything else that they should be watching for?

[00:31:49] Dr. Roxana Geoffrion: So are you talking about all women or women with severe perineal tears?

[00:31:54] Melissa Dessaulles: Yes, I think perineal tears in general. They should be getting better with time, right? Yes. Is there, you know, [00:32:00] symptoms should be getting better, discomfort should be getting better. Anything else like signs of infection?

[00:32:05] Dr. Roxana Geoffrion: Absolutely. Yeah. So we know that especially women with the more severe tears can have, you know, their incisions can open, they can have any sign of infection might include puss drainage or an unusual amount of new pain or fever or chills and so on. So those are you know, think of it as any sort of surgical incision that needs to heal. The course of that for sure. And the other thing, so women regain function slowly postpartum. Sometimes, you know, the one thing that's not often discussed is sexual function. Women go back to sexual function and there are significant delays for women with the more severe perineal tear.

[00:32:42] So everything is delayed in terms of bladder, bowel function, but also sexual function. And so that's the one thing that is absolutely never discussed at the six week appointment because women are just getting back into it. But if women start experiencing pain with intercourse or other unusual symptoms or [00:33:00] body image issues or leakage during intercourse that they had never experienced, it's very important to go back to their providers, to and get the adequate care for those kinds of symptoms as well.

[00:33:08] Melissa Dessaulles: Great. And I think that's important to kind of advocate for yourself, know who to reach out to. A lot of people ask, when should I see a physio or you know, do I need to wait for my six week checkup? Usually what I tell people is, similar to the person on the sports field I want you to reach out as soon as you're ready. I would never do anything invasive or cause any pain initially. I basically want to talk you through an acute musculoskeletal injury, and I want to talk you through how to work on swelling management, how to think about still managing at home with a baby. I want to help you regain your function, and I always say it would never be anything that goes against what your care provider has suggested. So I usually tell people, reach out as soon as you're ready. I would never do an in an exam. I would never do anything that you're not ready for in until the time is right. I think it's important for people to know that too. Cause I think sometimes they have to think, they think that it's gonna be aggressive treatment or that it's [00:34:00] gonna be painful treatment or that we're gonna ensure an internal exam and that's not how it goes. Absolutely. On a closing note, please talk a little bit more about your campaign because I want others to be aware of it and to help kind of spread awareness and what do you want people to know about it? I know I've looked at it myself, like your website. I love all of the the visuals, the videos that help people see some of these images. It walks through kind of perineal tearing and the different degrees, some of the things that we just talked about. And I noticed too that there's other ones about incontinence, about pessaries, so there's lots of great information on there. And so maybe if you tell the listeners a little bit more about your goal with the campaign.

[00:34:41] Dr. Roxana Geoffrion: Sure. Yeah. And so we know that it takes a very long time for research findings to be adopted by the medical community in routine practice, as well as for patients to be aware of what's going on, and even more time for the general public to [00:35:00] learn about certain research findings that have direct clinical applications to improve the health of patients. These guidelines they're evidence-based, meaning they're based on sound research and The Society of OB/GYN Canada produces them on a regular basis and updates them and updates 'em every five years with new information. At the beginning of my campaign, I thought wouldn't it be great if we came up with a delivery mechanism to make these guidelines easy to understand for all. And so the website intended audience and the social media campaign intended audience is everyone you know, medical professionals if they want to tune in, that's great. But it's mainly not just patients, pretty much anyone out there who has an interest in the topic and has questions about it. So we're taking guidelines and and we sat down with a knowledge translation specialist at the beginning of the campaign. This is somebody who takes medical information [00:36:00] and makes it simple for others to understand. And we essentially came up with this model of whiteboard animation videos, meaning we sit down with a graphic artist and a voice artist and write a script. The script of the videos is vetted by patient partners to make sure that the language used in the script is very simple and easy to understand. And then a voice artist will go to a recording studio to record the script. And then the script is put together with the images to make a whiteboard animation video. And so we got a funding from several sources from the Michael Smith Foundation for Healthcare Research in BC as well as even a private donor and some other educational grants for some of my students to come up with these whiteboard animation videos, and then we needed a means to deliver it to the online community. And we came up with this social media campaign as well as a website where [00:37:00] we can house these videos and we're planning to make one video for every guideline that the SOGC comes up with on, you know, we started out with obstetrical sphincter injuries and pelvic floor and pregnancy, because we found that those had the most misinformation about them. But we could plan to continue with other guidelines such as you know, frequent urinary tract infections in women and what to do about those and so on. So stay tuned for that. Or our campaign is also, we have several team members, so it's not just me producing these we work in conjunction with two pelvic physiotherapists, a patient partner, OB/GYN residents, so a resident learner in Obstetrics and Gynecology. As well as like I said, the graphic design and voice artists and so on to produce these videos. And the content is always reviewed for simplicity of language. So it's, we have a website bepelvichealthaware.ca, as well as a social media campaign. We're on Instagram and Facebook. I also have a Twitter account [00:38:00] where I regularly post stuff. Yeah, you know, hope that it's going to raise awareness through this, and you know, there are no graphic and you know, images out there. It's all all an animated sort of design video, and I hope that's accessible for all.

[00:38:15] Melissa Dessaulles: That's great. Cuz I think that there is, like you said, a big disconnect between yeah, clinical practice, but also getting it out to the listener. And I think that it makes it hard because at the end of the day, people are seeking out information from Google and social media right now, but then they don't know what to trust. And I think that but the medical system tends not to put out information that way. So it's kind of, they're looking for information from the medical professionals, but they're not looking in the right place. I think it's great that you're kind of bringing the worlds together.

[00:38:45] Dr. Roxana Geoffrion: Yeah. I think a lot of us are fairly weary of social media in the medical profession. Perhaps just have no time to really post stuff. But it's just so important to to let everyone know of what the latest updates are and research on certain topics.

[00:38:59] [00:39:00] And that's a wrap.