All right. Well, thanks for having me. This is one of my favorite topics to talk about. So I'm hoping that at the end of this, I can get everyone on board that this is a role that's really important that we play in our practices. So I wanted today to talk to you guys about the role that urogynecologists play in the care of patients with obstetric pelvic floor trauma. To help you appreciate common sequelae that we see in this patient population in the basic management principles, and then to highlight special considerations when surgical management is required. So just some kind of basic information on obstetric lacerations. So almost 80% of women will have an obstetric laceration at the time of a vaginal delivery. The majority are first and second degree, and the incidence of obstetric anal sphincter injuries has historically been a little bit difficult to characterize. There was a systematic review that showed that the risk overall was about in 6.3%, but about 5.7% in the first delivery, and then if you're a patient with no previous OASIS, your risk is lower. So, you know, for pelvic floor disorders in this population, I always like to say that for patients who are pregnant, this is often their first foray with a pelvic floor disorder, right? Frequency and urgency, pelvic pressure, bowel control issues. So, you know, there is a role that we can play in this patient population. And so, you know, pelvic floor disorders affect over 90% of prima paris women in the first year postpartum, and when we think of the general risk factors for pelvic floor disorders, vaginal deliveries, obesity, connective tissue disorders, chronic constipation, all of this stuff can happen in younger patients, too. So, you know, the short and long-term sequelae from obstetric lacerations, you know, bleeding from the laceration site, wound infection, and women who have obstetric anal sphincter injuries, that can be up to 20% of patients. Perineal pain, perineal wound breakdown in patients with OASIS can be up to 25% of patients. Dyspareunia, fecal urgency, which can be in up to 28% of patients, anal incontinence, you know, can be as high as 60% in the short term, but that percentage can increase over time with kind of that honeymoon period where people get better and then they age and lose some muscle mass and then all of a sudden they're having issues that have come back again. Prolapse and incontinence. So, when I evaluate postpartum patients, you know, things that I'm doing, I review the obstetric history from the electronic medical record. If they're coming from an outside hospital, I have my team try and get that for me. I want to understand the mode of delivery and the indication if it was an operative delivery. I want to know what their OASI risk factors were. I want to understand the laceration that they incurred and how it was repaired. And I want to understand whether or not antibiotics were administered. And then things that I screen for, you can do it with or without a validated questionnaire at that visit. So, what's their pain like? We use a VAS scale. Are there any postpartum mood disorder symptoms? We give every patient the Edinburgh. We ask them about how they're feeding their baby. And then we ask about the, you know, all of these were P's. So, I decided to go with that to help everyone remember peeing, pooping, and prolapse. And then things that we have handy are all things that are already in your clinic, right? So, you know, we use a Peterson speculum. We use the POPQ stick. I want to look at GH and PB. Sometimes you'll see a disproportionately enlarged GH and a really short PB. Cotton swabs, silver nitrate. There's a lot of granulation tissue that I see in this patient population, a suture removal kit, suture and suturing supplies. I don't really use that that often because usually if they've opened up, you know, there's a reason and we got to let some secondary intention happen. We have hand mirrors in every room. There's this really unbelievable perception that now they have this Frankenstein vagina after they've had a tear. Lidocaine jelly and amla cream for kind of minor procedures. Trigger point injection supplies. So, a lot of times I'll see patients that have fully healed but are having still a lot of perineal body tenderness from scarring and sometimes just a simple trigger point injection can significantly improve their pain. You know, supplies to irrigate, vaginal dilators, potentially pessaries for some of your maybe pregnant patients or postpartum patients who are healed but having incontinence or prolapse. You've seen this classic picture of the dovetail sign already today. So, when I evaluate postpartum patients, the first thing I do is just look and a lot of these patients are within a few weeks of delivery. They're very concerned about what this exam is going to entail and if it's going to hurt them. So, I just start first by looking for any vulvar erythema. There's a specific pad brand that I'll see postpartum patients using and you will have a contact dermatitis like in the exact outline of the pad. Is their perineum intact? I mean, I'm kind of just gently moving the tissue side to side. Is there any evidence of infection? This can be a little nuanced and subtle in this patient population because a lot of them are still having lochia at this point, but we'll talk about infection a little bit more. Is there any fecal soiling? So, is it just on the perineum and could that be because they're too afraid to wipe and they're just using a squirt bottle and maybe didn't clean up as well or is it because they're actually having FI? And then obviously looking, is there any stool in the vagina? The dovetail sign, is the anal opening just patchless? Are there hemorrhoids that are bothersome? I measure and will probe any defects just using the pop cue stick because most of the time when you see these patients and they have a wound breakdown, which is one in four potentially, you know, you're not going to do something about it that day. So, I like to have those measurements in my notes. So, when they come back, I have some objective data on how they have changed since the last time I've seen them. We use Epic and so, you know, you can take patient photos and upload it and that's really great on the Haiku app for people who are using Epic. So, I ask the patients like if they're okay with me taking a picture and then sometimes they really appreciate being able to see how things have changed over time as well. And then as I mentioned, I like to measure genetic and PB. I use half of a pediatric speculum or a Peterson along the anterior vaginal wall just so I can get a better look at the posterior wall, look at the sulci, if they had sulcal tears. We do a lot of forcep deliveries at Ohio State. So, it certainly keeps my clinic busy. I want to see if the suture lines are intact. Is there any granulation tissue? Are there any gross abnormalities in the healing? And then I start with just a one-finger exam and almost universally patients tell me, wow, that wasn't as bad as what I thought it was going to be. And you can get all the information you need from just doing this. So, I palpate the pelvic floor muscles. I'm evaluating for tenderness, hematomas, any fluctuants, is there a levator avulsion, which unfortunately happens with some obstetric deliveries. And then I do a digital rectal exam if it's indicated. But you can also get a lot of information by just looking at the anal opening. Sometimes patients are just, they've never had a rectal exam. They're not psychologically prepared for it when they come to see you. And by the way, their hormones are, you know, significantly changing. They're sleep deprived. They're emotional. They have potentially a complication or symptoms they never even realized they could have. So, you kind of have to meet the patient where they're at. So, I'll even just look at the anal opening, see what it looks like at rest, ask them to squeeze and you can get some information on what's happening with that squeeze. Do they have concentric radial folds all the way around or like with the dovetail sign? Are they missing anteriorly? So, that can be really helpful. So, first let's talk about some bladder control issues. So, we know urinary incontinence is more common in pregnancy than ever before and it can occur in up to 60 percent. And of primiparous women who are continent prior to pregnancy, 46 percent had urinary incontinence in pregnancy or postpartum. The prevalence and severity of urinary incontinence increased during pregnancy and peak in the third trimester. And we know, as I mentioned earlier, frequency and urgency are really common even at 12 weeks. It's in 74 and 63 percent and they remain pretty stable in pregnancy. Postpartum urinary incontinence ranges from 3 to 40 percent. A systematic review found that the prevalence of any urinary incontinence was 33 percent at 3 months. Weekly and daily urinary incontinence were 12 and 3 percent respectively. The mean prevalence was greater in vaginal compared to cesarean deliveries. And there were only small changes in urinary incontinence that occurred over the first year. We know that childbearing is an established risk factor for urinary incontinence. Parity is associated with an increased risk of stress and urge and a vaginal delivery further increases the risk of stress incontinence. Increasing age, BMI, family history of urinary incontinence are risk factors for urinary incontinence in pregnancy. And then vaginal birth and urinary incontinence in pregnancy, not surprisingly, are risk factors for postpartum urinary incontinence. A longitudinal cohort study that contacted patients starting at 3 months out to 12 years found that persistent urinary incontinence, and this was stress greater than mixed, greater than urge, was in 24 percent at 6 years and 38 percent at 12 years. And, you know, basically three quarters of women who reported urinary incontinence at three months continued to report it at 6 and 12 years respectively. So how do we counsel these patients, right? So with expectant management, we know it'll get better with time alone. They can try some behavioral and lifestyle modifications. So weight loss, potentially losing some of the baby weight. We know from the PRIDE study that, you know, it can reduce weekly incontinence episodes in overweight and obese patients. Fluid management. So sometimes these patients feel like they just need to drink to excess to maintain their milk supply and they're drinking over a gallon of water a day and you can tell them, like, why don't you try and just slowly titrate it back to maintain your milk supply, but also not be having some of these ramifications. And trying some time voiding so they're not getting into those situations where their bladder is super full and then they're lifting something heavy and leaking. They can do pelvic floor muscle exercises and pelvic floor PT. You know, we know that this aims at strengthening the urethral sphincter and the levator ani muscles. Many of these patients can't do a levator squeeze at all immediately postpartum. And so it's helpful to have some guidance. I'm really fortunate at my institution that we have kind of a fast-track program for postpartum patients to get in at a short interval because my typical urogyne patients, it'll take like two months for them to get in for an appointment and then you've totally missed almost the whole postpartum window for many patients when they would actually have time to go to an appointment. And you know, this can be alone or augmented with bladder training, biofeedback, eSTEM. There was an RCT of pelvic floor PT versus no intervention that found significant improvement in stress incontinence and related bother and increased muscle strength and endurance at six months postpartum. So there is a role. The incontinence pessary can be an option for patients who are postpartum, ring with knob, incontinence dish, with or without support. It's a good option for patients who are looking for a more immediate symptom control than what's provided by PT. You can fit them as soon as six weeks postpartum or earlier if no laceration is there or they're well-healed. Six weeks as we all know is pretty arbitrary. It's just a time that patients traditionally check in postpartum. And patients can self-manage or use it as a bridge while their body heals and things kind of normalize. They can also use it as needed when stress incontinence is most bothersome. So, you know, if they are leaking every time they're working out or doing any kind of heavy lifting that, you know, that can make the idea of a pessary a little more feasible. And it is feasible in postpartum patients and research studies. There's the over-the-counter vaginal inserts. Obviously, it's similar to a tampon. We all know what these are. They have a fitting kit. They can be good for women who have predictable stress incontinence. Other options, if the patient's breastfeeding and they have some atrophy on exam, you could consider vaginal estrogen. We know there are estrogen receptors in the urethra. It's not going to hurt. It's not absorbed in any, you know, meaningful amount. It doesn't affect milk supply. I typically would wait until at least six months given the natural history of stress incontinence before doing any kind of anti-incontinence procedure like bulking or a sling. For overactive bladder symptoms, I tell patients, again, this will get better with time. They can do behavioral and lifestyle modifications, some of the things we talked about before. Avoiding bladder irritants, urge suppression techniques. If they have a baby that's sleeping and they're having bothersome nocturia, cutting back fluids a couple hours before bed. And then pelvic floor PT. As far as meds go, we know anticholinergics can pass into the breast milk. They can cause excitement or irritability in a baby. Long-term use could also reduce milk production or let down. And a single dose isn't likely to interfere with breastfeeding. So if you have a patient who has a calf that urine is really bothered by it and you want to use some, you know, short-acting oxybutynin, that's not really going to affect their milk supply. But long-term use, you know, would not be indicated in that population. As far as the beta-3s go, there's no risk of harm or impact on milk supply with use during breastfeeding. But there is possible excretion in the breast milk due to the known drug properties. So maybe not a good option either. As far as third-line therapies go, you know, you're thinking about that obviously for continued refractory symptoms. I would wait until six months, again, knowing kind of the natural history of how things go in order to give time for peripartum changes to normalize. Sacral neuromodulation, they recommend it's turned off in a subsequent pregnancy if you had someone who had really refractory symptoms. For onobotulinum toxin, it's not recommended while breastfeeding. There was a study in the plastics world where they did detect botulinum in breast milk when used for cosmetic indications, but it was well below the lethal dose. And then for patients who are going on to have a subsequent pregnancy, you know, you could time the time that you do the Botox to get them through, you know, a good portion of their pregnancy potentially. As far as prolapse goes, obviously, we know it's really difficult to tease out contributions of a vaginal birth, operative delivery, episiotomy, OAC on future pelvic floor function. We know that pelvic organ support defects can appear during pregnancy and even before delivery. But with a vaginal delivery, there's significant stretching of the levator ani muscles, which can lead to muscle and nerve stretching and injury and damage. At eight weeks postpartum, 52% of primiparous patients were POPQ stage 2 on exam. 47% still were POPQ stage 2 on exam at one year. And this prevalence was three times higher at one year and women with a GH greater than four at eight weeks postpartum. What I tell patients is that with time, your prolapse will likely get better. And reassurance can go a long way. Sometimes, you know, when they're over six weeks postpartum, I'll do a POPQ exam just so I can objectively show them their numbers have improved. And I've had multiparous patients who come see me postpartum that have, you know, severely bothersome prolapse and they are like, Dr. Hickman, I want to be on your schedule at six months and one day for a repair. And then they cancel at like five months because things have gotten significantly better. Not all, but some. You know, pelvic floor muscle exercises and PT, we know that improvement in the pelvic floor muscle tone can improve GH and overall strength and that can contribute to less bother and likely better support. And it's not gonna hurt to have patients do PT postpartum, but the data is a little bit mixed. Pessary, again, you know, you can fit patients as soon as six weeks or probably earlier if they don't have a laceration or they're well-heeled on exam. Again, they can self-manage as a bridge while their body heals or if they are happy with it, use long-term. You know, the other thing is even patients who have severe, you know, bothersome prolapse, it's really hard to have a prolapse surgery while you still have a very small baby at home. You know, even if they were eight or nine months out and it's, you know, their third child, like usually the older kids are the harder ones. For anyone who has kids here, you know that. So, you know, the timing, you know, we really need to try hard for these patients to get them symptom control until the time is right if they really do have significant prolapse. I also tell them they can use their pessaries just as needed. And again, it was feasible with symptom improvement in postpartum populations. So what about very symptomatic patients? So I wait until at least six months before I'd talk about surgical management because there is so much dynamic change that happens. Again, as I mentioned, you can provide reassurance. You can document the POPQ exams at intervals so you can discuss how things are changing and improving. And then if they're still bothered at six months. If someone really wants another pregnancy, you could think about a hysteropexy potentially. A lot of times it's isolated posterior compartment. They had a bad tear. That wall is weak, and the muscle is separated. And sometimes you can just get away with a posterior repair and peroneurophy. How about bowel control issues? So in a PFDN prospective cohort study at six weeks, postpartum fecal urgency was reported in 28% of women with lower degree tears and 38% of women with OAC. And a Canadian prospective cohort reported fecal urgency in 6% to 28% after OAC in a follow-up period of one to 30 months. So it's really common. I have patients that I see who all the time have fecal urgency postpartum that they never had before. And it makes sense with the muscles that were injured and some of the things that Dr. Richter had mentioned in her presentation too. As far as anal incontinence, at eight weeks postpartum, it's present in 23%. After an OAC repair, it can be even higher than that in almost 2 thirds of patients. Women with OAC have greater FI, flatal incontinence, and fecal incontinence severity at six weeks and six months than women with lesser tears and 10 times worse bowel control with a fourth degree. The overall prognosis is good. So 23% flatus incontinence and 4% of liquid FI at 12 months was seen in primiparous patients. And 68% of women with OAC had no symptoms of AI at all at 12 months. But there is this honeymoon period that I mentioned at five to 10 years after their first delivery. So what can we do? We can educate on normal and abnormal bowel function. Simple education and diet modification and urge suppression techniques were as effective as pelvic floor muscle exercises or biofeedback in a study. And education and standard medical care increased success in up to 40% with individuals who are refractory to medical management alone. So some very basic things can go a long way for this patient population. As far as other things, you should evaluate for other coexisting contributing conditions and treat accordingly. Because as we discussed earlier, FI is often multifactorial. Ritualizing bowel habits, improving skin hygiene may be weight loss in some studies, but that's a little controversial. Avoiding food triggers, avoiding things that increase colonic motility, especially if they're not going to be close to a restroom. As far as medications go, this is in line with what we already discussed today. Bulking agents, anti-diarrheal agents, and then ion exchange resins can be helpful. E-stim we know is not actually effective in postpartum patients, and it actually made FI worse, so I wouldn't recommend that. And then there are home vaginal biofeedback devices that improved symptoms and quality of life in a small pilot study, but it's not yet been studied in postpartum patients. So when do we surgically intervene postpartum? Well, if a patient has a history of an OASI with a visible defect, like a dovetail sign or an absent or minimal perineal body and significant breakdown. If they have symptomatic FI with a known sphincter defect on exam or imaging, obviously if they have a rectovaginal fistula, you're going to intervene. And you can intervene early, like median postpartum day 20 in Christina Lewicki-Gaub's data, but let the tissue quality be your guide. And patients don't need to stop breastfeeding. That's a common misconception, but if you think about it, postpartum atrophic tissue is really not that different than the postmenopausal tissue that we deal with, where you're telling your trainees, ease up on the tugging. It's going to tear. How about wound healing abnormalities? So the incidence is 10% overall, but up to 20% for OASI. You typically see it in the first two weeks postpartum. We know that infection and breakdown are often linked. And you may not see frank purulence or classic infection signs and symptoms, but in my experience, like an acute worsening of pain is typically the presenting sign, and their pain is out of proportion to your exam findings. And these are the patients who are sitting on their side. They're standing up in the room when you walk in. They can't even sit down because it hurts so bad. And I always tell our obstetric colleagues worsening pain postpartum in the perineum merits an office exam. We know that it's reasonable to give antibiotics intrapartum for women who have OASI. It's a level B recommendation. And in one study, there was a three times decreased risk in wound complication incidents at two weeks in an RCT. And there are hospital initiatives to increase the antibiotic during OASI repair, and that resulted in a 55% decrease in infection and breakdown. And this is where we kind of need to liaise with our obstetric colleagues. If someone has superficial erythema without an extensive breakdown, you can give them Keflax. If they have a significant wound breakdown, I often do Augmentin and Flagyl for 7 to 10 days. Augmentin will give you that gram positive and gram negative coverage. You get some anaerobic coverage with the Flagyl. Both are safe for breastfeeding, but you want to mention the risk of thrush to the baby and counsel about the incidence of infant diarrhea. But anyone who's had a newborn knows that all their stools in the beginning are very loose, so I tell patients you're probably not going to notice a big difference. If they're penicillin allergic, I'll use Levoflox. Pain should start to improve within three to five days of starting antibiotics. And this is just clinical observation in my office of asking patients, when did you feel like your pain started to get better? And then if it really seems unusual, you could swab and send it for a wound culture, but oftentimes these things just come back as polymicrobial and don't end up being that helpful. You know, encouraging perineal hygiene, so you can have them be pretty aggressive with a perineal bottle, all the other kind of peri-care things that we talk about. And then close outpatient follow-up is really key, and making sure they understand what the warning signs and symptoms are and when they should call the office. As far as perineal breakdown goes, it's up to 25% after an OAC, and the risk factors for perineal breakdown include things like having an OAC, chromic suture in the repair, increased BMI, tobacco use, meconium stained amniotic fluid, prolonged second stage, operative delivery, episiotomy, midwife repair, and then postpartum antibiotic use. But we know, again, that intrapartum antibiotics are protective. So what do I do when I have a perineal breakdown? Well, I do an educational exam with the patient, if they are mentally in a place where they can tolerate it. Some people don't want to see it all. But I will trim any excessive suture. Usually, when they have a breakdown, it just looks like a bird's nest of suture, and you just, none of that is helping, so you might as well just get rid of it. You can irrigate the wound out. If there's any kind of excessive granulation, you know, you can debride it. And then measure and document the defect in your note. Again, we talked about you can use a photo and that can be really helpful. And the majority, especially small defects, you can conservatively manage. Avoiding antibiotics unless you feel like clinically they're indicated, sitz baths, wound packing would be pretty rare. One thing that I actually learned from a patient was Manuka honey. I had a patient who had a rectovaginal fistula and sphincter separation. I did an RVF repair for her. I did an RVF repair and sphincteroplasty on her. And man, there was this one area on her perineum that for months we could not get to heal. I had treated it with silver nitrate. We had tried everything. And she started Manuka honey on her own. And then she came back and it was healed. And so I know that we should never practice end of one medicine, but so I went to the literature. And it is FDA approved for minor burns and ulcers. And there have been studies in kind of skin and wound care journals. And so how does that help? Well, it has anti-inflammatory, immunomodulatory, and antimicrobial properties. The high glucose content creates an osmotic effect. It reduces edema and aids in wound healing. And it also has some peroxidase activity, which can help with wound inflammation and healing. And it has been reported to have benefits in burns, chronic non-healing ulcers, and post-op incisions. It's over the counter. You can buy it from Amazon. It's well tolerated. And it's overall low risk. I have had other patients use it, again, who've had stubborn wounds since my index patient. And it really can help with healing. And patients feel good because they're actively doing something, too. OK, so we've tried all these conservative things. But in your mind, when are you thinking, like, oh, we're going to have to take this back to the OR? Well, obviously, if there's systemic symptoms and concern for a peroneal sores, you're probably going to have to take that patient and debride them. Obviously, if there is external anal sphincter or rectal involvement, you're going to have to take them to repair it. If you have concern for compromised pelvic floor support and their anatomy is significantly distorted, or if there is kind of just lack of appropriate healing with conservative management, things are not healing it enough that you're ever going to restore normal anatomy with secondary intention alone. So in the literature, we know that there's like a 5% to 10% chance that you're going to end up taking one of these patients back to the OR in subspecialty postpartum pelvic floor clinics. As I mentioned earlier, Christina Lewicki-Galbstader, she had a median of postpartum day 20 for repair of patients. And this included fistulas and sphincteroplasties. And there was no increased risk of wound complications or breakdowns or anything like that. A lot of times with these peroneal breakdowns, you're going to do some sort of peroneorphy, potentially a vaginal advancement flap. If there's anal sphincter involvement, you might be doing a sphincteroplasty at the same time based on the patient's symptoms. For a vaginal advancement flap, you're typically doing this if you have concern that there's going to be some excessive narrowing. And so I'm just kind of putting my alices along the back wall. You're undermining it so you can move it distally. And then you're closing in a horizontal fashion. How about fistulas? So obstetric injuries account for 88% of all rectovaginal fistulas. Incidence is about 0.1% of all vaginal deliveries in the Western world. But in women who have OASI, it's more like 1% to 2%. The risk factors for an RVF are primiparity, prolonged labor, home delivery, instrumented delivery, midline episiotomy, which we just know globally increases your risk of an OASI, and then you can break down and increase birth weight. On these patients, I do a thorough history. I do a bi-digital exam. I feel like the best trick I ever learned was to put some methylene blue or indigo in surgical lube and then use that for a rectal exam. And you can kind of milk it along the back wall. And if you see any blue in the vagina, even if it's hard to see the track, I mean, you can put a Proctoswab in there. Sometimes these patients aren't super tolerant of exams. So what you can accomplish in the office isn't the same as some of our other patient populations. But it really, for me, has helped identify a lot of really small fistulas on exam. You could do a tampon test with methylene blue into the rectum, exam under anesthesia. Obviously, things like rigid proctoscopy is not in most of our wheelhouses. You can do a bubble test. That's obviously uncomfortable to have to be pushing that kind of bolus of air in the rectum in an awake patient. But if you're doing an EUA, we just did that on a patient the other day in the OR. And then obviously, if there's any concern for fistula in the upper rectum, you'd want to get some imaging. And then also, endoanal ultrasound can be helpful. You can see the fistula tracks with these 3D probes as they kind of recreate the 3D image, CT enterography or a barium enema. So at first, you want to kind of allow for maximum resolution of inflammation. And some of these big, immediate postpartum breakdowns with fistulas, they will get smaller just with a little bit of time. Theoretically, very small fistula can heal spontaneously. You'd want management, consider vaginal estrogen. Antibiotics is needed. Maybe a diet where their stool is soft-formed, easy to pass. But limited data says it's about 50%. As far as operative management goes, you want to allow for maximum resolution of inflammation. There's no consensus regarding preoperative prep. What I do, and again, some of this I acknowledge could be voodoo. But I have patients start on Miralax five days prior because I just want to make sure that these patients who want to constipate themselves so they're not leaking stool through the vagina don't have a first very constipated bowel movement on the suture lines that I've just repaired. I have them do a clear liquid diet 24 hours before surgery. I don't do a bowel prep. They're just miserable if you do that. And they come in dehydrated. That obviously doesn't help with breastfeeding either. And then I give a broader spectrum cephalosporin like cefoxitin. Or you could do anceph and flagell. So I repair as soon as I feel like the tissue is in a good place to do it. I typically repair these transvaginally. Diversion is not typically indicated, especially if it's a first go around obstetric fistula. And to sphincter aplasty or not, I think you just have to ask your patient. And it can be really confusing. But the board question is like, why did they keep having fecal incontinence after you fixed their fistula? Well, it's because you never asked about their sphincter, right? So you have to understand, are they having any anal incontinence per anus, which can be really confusing when they also have a tract through the vagina? You're also assessing for the dovetail signs, sphincter weakness on a digital rectal exam. You can perform an endoanal ultrasound. The pro is that it helps with opposing suture lines and depth between the vagina and the rectum. The cons, it's longer surgical duration, increased pain, higher wound breakdown risk. So principles, complete excision of the tract. There was a lecture I listened to of Dr. Culligan's that he recommended a Keyes punch biopsy. And I found that to be really helpful in practice. Wide mobilization of the adjacent tissue plane, a multilayered tension-free closure with opposing suture lines. You want to avoid dead space and use liberal irrigation. I use usually a 3-O monocryl on the anal mucothy. I like to do interrupted sutures. And then I do a second layer using 3-O PDS to imbricate over the anal mucosa. And you're kind of incorporating the internal anal sphincter into this, if possible. Sometimes it's a little hard to see. And then if I do an anal sphincteroplasty, I try to do an overlapping repair using 2-O PDS. Kind of an additional peroneorphy layer if you need it to avoid dead space, which in my experience, you typically do. And then any kind of back wall peroneorphy sutures as usual. And then 2-O Vicryl is what I use to close the epithelium. Again, these are my considerations. Low residue diet, which I have them do for the first couple of weeks. I have them do mineral oil once a day until their first bowel movement, so things just kind of come down nice and lubricated. And then I have them do Miralax. And you can add some Colace too. But I have them titrate it to a Bristol-4 stool. They can do sits baths or a peri-bottle, dry with a cool hair dryer. There's really no data on antibiotics post-operatively. They don't need a pump and dump. They can lift their baby. I try and see them at short interval. I have a low threshold to treat infection. And minor breakdowns are common, so I kind of prepare them that they may have a stitch that opens up, but we can manage that. Don't forget about psych assessment. PTSD is really common in this population. Postpartum mood disorders, pelvic rehab after healing, and then counseling on subsequent deliveries. So in summary, postpartum obstetric laceration sequelae, I believe, fall under our purview. We have an excellent understanding of the pelvic anatomy. We have all the supplies on hand already in our offices. We have training in complex reconstructive surgery. And our obstetric knowledge for the OB-GYN track IRPS people enables us to really do a great job cross-collaborating with our referring providers. We know that these are so common in postpartum patients, up to 90%. And this, as I said, is often their first pelvic floor disorder experience. For many, education and reassurance go a long way. For those who are symptomatic, conservative measures are available. And if symptoms persist more than six months, then you can consider management similar to other reproductive age patients. We know that managing breakdown and infection go hand in hand. Start conservatively. If this isn't effective, then surgical intervention may be indicated. Wound revisions are common techniques and procedures. Rectal vaginal fistula repairs use all of these very familiar reconstructive principles. And anticipatory guidance, referral to other providers is indicated. And close post-op care is essential. I put some resources here. The OGS and the iUGA handouts are really great. The Green Top Guideline from RCOG and then the ACOG guideline. This is my website. This is a paper I wrote if anyone has interest in starting kind of a peripartum pelvic floor disorder clinic. It can be a really nice guideline to help get you started. And thank you for your time. And I welcome your questions.

urogynecologists

obstetric pelvic floor trauma

postpartum disorders

urinary incontinence

pelvic floor exercises

surgical intervention

wound healing