୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧୧ All right, I think we can probably get started now. Welcome to the AUG's urogynecology webinar series. I'm Lauren Stewart, the moderator for this evening. Today's webinar is titled Starting a Peripartum Pelvic Floor Disorders Clinic, Why and How? Our speaker today, Dr. Katie Propst, is a urogynecologist at the University of South Florida. She's board certified in OBGYN and FPMRS. Dr. Propst serves as the division director for urogynecology and reconstructive pelvic surgery, fellowship director for FPMRS, and director of the Pregnancy and Postpartum Pelvic Health Clinic. She's the co-founder and chair of the Childbirth and Pelvic Floor Disorders Special Interest Group here at AUG's, where she works collaboratively with other experts from across the United States. Just a few last minute reminders, the presentation will run about 45 minutes, and the last 15 minutes will be dedicated to question and answer session. Before we begin, I'm just going to review a few housekeeping items. AUG's designates this live activity as a maximum of 1.0 AMA PRA Category 1 credits. To claim your CME credit, you must log into the AUG's e-learning portal and complete the evaluation following the completion of this webinar. The webinar is being recorded and live streamed. A recording of the webinar will be available on the AUG's e-learning portal. Please use the Q&A feature of the Zoom webinar to ask any questions throughout the webinar, and we'll answer them at the end, and use the chat feature if you're having any technical issues. AUG staff will be monitoring that. All right, Dr. Probst, take it away. Great. Thank you for having me, and thank you for that kind introduction. So I'm happy to be here tonight to talk about this topic. I don't have any disclosures. So the main objectives for this talk are really to think about the logistics of starting this type of clinic. We're not going to talk about clinical care or clinical paroles. We're really going to focus on how to start a clinic. So when you start to think about why you're going to start this clinic, there's some really obvious benefits for this. There are benefits for our patients in that often antenatal education is lacking. There's not a lot of support available to women with traumatic birth. Some birth complications can lead to significant long-term complications. Follow-up is essential, as is education, and these things are often lacking. We all know that there's not a lot of exposure, especially to OAC, for trainees and providers in practice, and so there can be problems with accurate classification and repair of lacerations. And there just aren't a lot of experts, so there are definite benefits for our patients. There are some institutional benefits as well. The institution gains a provider with expertise in uncommon issues. They gain education of their obstetric providers and trainees who can fill a gap in patient care. Often, there's a lot of positive publicity from this type of clinic because typically you are filling a gap in care. You can generate revenue from new consults. There tends to be a lot of high patient satisfaction and referring provider satisfaction, both from my experience and in the literature, and there's some evidence that there's decreased litigation given these types of clinics. There are benefits for our trainees as well. With an exposure to this specific patient population, they get to learn about the natural history of OAC. They can see some of the complications from an operative vaginal delivery and learn about a lot of very part of pelvic floor disorders, which in turn should help us in the future get better care for this population of women. So, starting a new service line is a lot of work, and you want to make sure that you know why you should be the person to do this so you don't end up in this situation here like Charlie Brown asking yourself, why did I start this clinic? You want to take a lot of time in the beginning to think about why should you be the person to do this. And your why is really at the core of your work. It's your purpose. It's what drives you. It's really your cause. So, you have to get to this, and it's important to do this work before you start because all of those patient, institutional, and trainee benefits may not be enough to drive you. You have to think about what's going to keep you going as you run this marathon. So, I want to tell you a little bit about my why, and it really starts with patients. So, I'm going to tell you about a patient that I cared for in a postpartum clinic. This patient was 29 years old. She's well-educated, and she came to see me after having her first baby. She had a highly desired pregnancy. She was diagnosed with maternal exhaustion after pushing for three and a half hours. She had a forceps assisted vaginal delivery, a fourth degree laceration, and bilateral focal lacerations. She sustained a wound infection with breakdown. After delivery, she had no bladder sensation and was in urinary retention until postpartum day 20. She developed anal incontinence, and she subsequently attended nine months of physical therapy to regain her normal bladder function and to improve her anal incontinence. And from her perspective, when I met her in clinic, she felt like she didn't know anything about the forceps that were used for her delivery. She felt like no one explained it to her and that she had no choice. She felt like she was explained the potential risks to her baby from a forceps delivery, but not to her own body, so she felt uninformed. She didn't understand that she could have such a wound from this type of delivery or that it could have complications, that she could have trouble with bowel or bladder control. And before this delivery, she had a strong desire to have more children. But now, given everything that had happened to her, she was really uncertain about her future childbearing, and she felt a sense of loss for herself and her husband and had a lot of difficulty with that. So this patient perspective of feeling uninformed or having their care being lacking really is a touch point for me and drives a lot of what I do. So that's a big part of my why. Another part, in addition, is the psychological impact for women from traumatic deliveries and especially from OAC. I hear this from my patients, but also if you do even just a quick Google search, you can find that there are many online support groups, blogs, conversations of women trying to support each other where they feel like the medical system has failed them. This is a motivator for me as well. And then thirdly, my final motivator is really, hopefully, to improve care of women long-term. So not only being a listener for their patient stories, caring for them postpartum, I also have the opportunity to provide education to trainees and obstetric providers in practice that could be lacking, and also to see something that's uncommon frequently, which gives me an opportunity to identify problems within how we're caring for patients and have quality improvement initiatives. So these are the things that drive me to continue to do this work. So once you've identified your why, you're ready to get started in building your clinic. So there's some important initial considerations during your planning. And it's important to know that this is a prolonged process, this will take time. So once you've figured out your why, you want to give a lot of time to get all of this infrastructure in place before you start. And you really need to allow six to 12 months to get all of the groundwork laid. And you really have to start with gaining support from leadership. So I would recommend that you definitely want to engage your department chair. Many departments also have an obstetrics chair or an obstetrics director whose support you'll want to gain as well. You also want to engage the obstetric providers who are going to refer patients to you. You want to talk to them about what you envision, what they feel is needed or lacking at the institution. You want to emphasize to all of these individuals that the aim of the clinic is for you to work together with obstetric providers to support women with pregnancy and postpartum-related pelvic floor disorders. You can also point out that this clinic may offset some of the burden of obstetric providers in a busy practice. Some of these visits may take longer than the average postpartum visit. And so you want to point out that you can provide some of that support and give them some relief from that. The other thing you want to point out is that because you're often providing a new service that's lacking, this can give them a lot of positive publicity for the institution. There are studies showing high patient satisfaction that this can generate revenue and even lead to decreased litigation like I mentioned earlier. Now I've been lucky enough that thus far the institutions where I've worked have been supportive of this type of clinic. So I have not had to negotiate how to convince someone that this clinic is needed. But if your leadership is initially skeptical, I think you want to provide some of the literature that exists that show both patient and provider satisfaction. Some papers in the literature show volume from prior clinics and you can bring some of that data to support that this is a viable service line. You want to come prepared with knowing how many deliveries occur annually at your institution and what kind of volume you expect and talk about all the benefits of a new service line. So the next step is focusing on your clinical logistics. So you first want to figure out who is your target patient population? Who do you want to see? You have to think about timing of their appointments and what's going to be your timeframe for follow-up. So in the postpartum clinics that I've worked in, when I initially started, I thought that obstetric providers would not want to refer patients to me. I thought that they would only be willing to send me OAC patients and that the other patients they would feel like I was stepping on their toes or I was trying to say I knew more than they did about complex deliveries. And I was really wrong. I thought that I was just going to be running an OAC clinic, but I realized there are many other pelvic floor complications that are related to traumatic birth that many obstetric providers are looking for support to care for these patients. So I set out to see OAC patients, but that has really changed over time just based on the referrals that I was receiving. In the beginning, when your clinic is getting off the ground, you want to be really flexible and open to referrals and understanding why people are sending patients to you, which is what I did. But I found a lot of other issues that providers wanted consultation on. So at this point in my practice, I see in my peripartum clinic, women with OAC, any other type of complex laceration, wound complications from any type of laceration, bowel and bladder control issues, urinary retention, dyspareunia, pain, fistulas, prolapse. So I see consults for any of those things. I also do antepartum consults, and this is primarily with women who have a history of OAC. Sometimes it's good for patients to have a dedicated appointment to talk about their prior OAC, why it may have happened, and how they should deliver in the future. Also, I may see some women who had prolapsed or incontinence before their pregnancy who want to talk about management afterwards, or women with a history of surgery for prolapsed or incontinence who want to talk about delivery planning. Timing of appointments relative to delivery will depend on what your patients are presenting with, but I aim to see all women with OAC within two weeks of delivery. And I take consults in this clinic up to one year postpartum. Now if a woman has a delivery complication that doesn't, that she's not referred for until much later, she's seen as a urogyne patient, so she's still cared for, just not specifically in this dedicated clinic. More things to think about are where you will see the patients. And any gynecology office space is really sufficient for caring for these women. And you want to make sure some standard supplies are available. Now most of the things you'll need would be available in the GYN office, and that's things like suture removal kits, wound irrigation kits, silver nitrates. You want some local anesthesia, both topical and injected, for procedures. You'll need equipment for performing IMD of abscesses and suturing, vaginal dilators, and pessaries. You also want to think about the room space considerations. So many of these women are going to come to their appointments with their baby in a stroller, and sometimes with one or two support people. So you have to make sure that the rooms in your clinic are big enough to accommodate these visits. You also want to think about things like baby changing stations. Space for nursing or pumping. For many of these women, they may need extra time to settle into their appointment, or to get ready to go afterwards, especially if they need to feed their baby. So they may need to use the room longer than the actual duration of the appointment. So this isn't the kind of clinic that you're going to triple book every 30 minutes, because that won't, the flow won't go very well if you do that. There are other things you want to think about for organizing your schedule, and that's when you're going to see the patients. There are two primary models of organizing this type of clinic. One would be to have a specific dedicated time, like a half a day once a week, or once every other week, where you only see these patients. The advantages of this type of thing is that it's, or this type of dedicated time frame is that you're going to be able to see the patients, and you're going to be able to see the patients, and you're going to be able to see the patients. So whoever is scheduling your appointments knows the specific day and time that they can always schedule these patients for you. It makes workflow easier for the staff supporting you in clinic, because they're seeing the same type of patient. So there are some logistical things that make that run pretty smoothly. The potential issue with that is, depending on your volume, you may end up with clinics that are not filled. So especially when you're starting out, it may be better to have appointments that are scattered through your current schedule. That way, if you have a slot that isn't filled, it's easy to fill that with another patient, or to have it be less impactful on your day. And as I alluded to earlier, these are appointments that you want to give enough time for. Later, we'll talk about setting up the clinic in terms of how you want to conduct the visit. But these appointments, sometimes they're long, sometimes they're not. These are not 15-minute appointments. You want to give adequate time to see these patients. So the next thing you're going to focus on is establishing a referral system within your medical record. Now, this is really important, because this is how patients are going to get to you. So there are different ways to build this in different systems, but this is what has worked for me. It's because the majority of my referrals are women who have had a third or fourth degree laceration at the time of delivery. This was initially built as a best practice alert that is released in the medical record when a patient is diagnosed with a third or fourth degree laceration, recommending referral to the clinic. And it's easy one-click for the provider to then just place that referral. So that's an easy way to prompt getting those referrals from labor and delivery, and it reduces the burden on referring providers. So any other patients, once that referral is placed, then the patients are educated on that referral so they understand what it is before they are discharged from the hospital. And then referrals for patients who are not in the hospital is completed in the same way you would do any ambulatory referral. So there's an order that can be placed in the clinic because some of your referrals are going to come from postpartum care or from physical therapists or others. So those are just regular ambulatory referrals. Once the referral is placed, that referral goes into a dedicated either work queue or in-basket that then you have a dedicated staff that will review those referrals. So for me, there's a dedicated nurse that looks at those referrals and reviews them for appropriateness to make sure you're getting the right referrals or the patient is appropriate for your clinic. They'll then contact the patient and explain the purpose of the referral. They'll evaluate her for any concerning symptoms. If there are patients who are having increasing pain or other things that are more urgent, it gives the nurse an opportunity to schedule that patient sooner. They'll reinforce care recommendations, things like bowel management, sitz baths, pain management, and then they will schedule that patient for an appointment. So one thing that's important to be aware of is that all of these things can take significant time to both develop and implement, depending on your medical record and resources at your institution. So you want to first talk to obstetric providers, understand the best way to have a referral system based on their workflow, and then start building it as soon as possible. I can't emphasize that enough. It's never too soon to start building this infrastructure. So the next challenge is making sure that referring providers understand the referral process. So you need to have education to a number of people who are going to be both referring patients or in contact with patients after they're referred. So you have to think about the ambulatory obstetric providers, appointment coordinators, labor and delivery, and postpartum nursing, advanced practice providers, midwives, and also laborists, hospitalists, and nocturnists. You want to make sure everyone understands the referral process and the purpose of the clinic. So communication is really key because these are the individuals who are not only going to refer patients, but also answer patient questions about what this clinic is and why they're being sent. So you want to make sure they understand. And there are definitely some solutions for this. You can do this in education seminars for providers or nurses. You can do grand rounds. Having that established clinic nurse as a point of contact also can be really helpful. And you want easily accessible, accurate information. So you may want to establish a website, which we'll talk about more later, or patient flyers that are simple that just go with the patients who get referred or adopt, praise, and epic that goes into their discharge instructions. So the next thing you're going to think about is developing a plan for appointment structure. So now you're ready to move on to some clinical considerations. And just looking back at this, a lot of this is in a specific order that we're going through. I think what's really important is what starts at the beginning. Obtaining support should be at the beginning, but a lot of these other things, even though it looks sequential in this diagram, a lot of this is happening simultaneously, right? You're thinking about your schedule while you're gathering information from your colleagues who would refer, start developing, meet with your epic or your medical record personnel, get some feedback from them. This is going to be a process that's not start to finish the way it looks in this diagram. So moving on to some clinical considerations. So it's really important that you get a lot of history from these patients, especially a thorough obstetrical history. And I think delivery type, laceration incurred, duration of the second stage, newborn weights, presentation, repair technique utilized are all really important things for you to gather. This obstetric history is important because it's going to guide counseling for risk stratification for future deliveries, especially for women with OAZ. And even though that primary decision-making may not happen, or will not happen in your visit with her two weeks after her delivery, in the future, that information will then be nicely put together so it can be considered in the future. One way to efficiently gather information about how your patient is doing is to have an intake form. So on this intake form, I have some obstetric data that the patient can give to me. Some of the other obstetric data will come from the medical record. And this is a way to efficiently gather a baseline about what's going on with your patient. It's a place to start the conversation when you walk into the examination room. Other things that I include on this intake form, in addition to obstetric history, are some validated questionnaires. I collect an Edinburgh Postnatal Depression Scale on all of these patients. Often, we are their first point of care after they leave the hospital within two weeks. And so this is an important thing to screen for. These women may have a lot of distress given the trauma of their delivery. And so we wanna make sure that we're checking in on this. I screen for symptom severity related to pelvic floor disorders, assess their pain using a visual analog scale, and also assess bowel and bladder function. So I wouldn't recommend at this moment a specific questionnaire. I think things that are important is to think about the length of the questionnaires that you're using so that your overall intake form doesn't become overly cumbersome for patients. You wanna think about how you're gonna use the information. And you also wanna make sure that you're using validated tools. Now, we don't have a lot of validated questionnaires in the postpartum population. So as long as the tool is validated in women for pelvic floor disorders, I think that's sufficient. The SIG that I'm involved in with AUGS that Lauren mentioned at the beginning of the session has been working recently to develop a recommended intake form that will soon be widely available. So keep an eye out for that. We're developing some educational and other resources for people starting these types of clinics. So as I said earlier, these intake forms are really a jumping off point to start a discussion with patients. Listening is really key in these appointments. So the patient often comes in, fills out her form, and while she's getting undressed for an exam, I review the form before I go talk to her. So before I walk in, I have a vague idea of what's going on with her in terms of pain, bowel and bladder function, and what her concerns are. But there are a lot of things that patients are concerned about that don't easily fit into an intake form. So listening is really key. This questionnaire just gives you a point to start with the patient. Some of these visits will be quick that patients are doing pretty well and aren't having any issues. Other visits may take an hour or beyond because patients have a lot of emotional things that they're trying to sort through or other complications that you find that require a lot of counseling. So listening to the patient is really important. And no matter what their form says, I always ask them, what are your concerns? What do you wanna talk about today? So once you've completed your intake, you're gonna move on to physical exam. And in this situation, I wanna do a thorough enough exam that I gather the information I need while respecting patient's discomfort. So I do a modified pelvic exam that starts just by examining the perineum visually. So I inspect their healing wounds, check for any tenderness or other signs of infection, breakdown, if there is a breakdown or separation, I will often measure that. After this, I do a digital exam to assess the pelvic floor musculature to look for spasm, tenderness and check strength. I'll then use the speculum broken into two and with the post-hair blade placed on the anterior vaginal wall so that I can see the sutures inside the vagina. I use a lot of lubricant when I do this. I do inspection of the anal opening to look for any, is it patchless? Is there a dovetail sign? I may do a digital rectal exam as well, depending on her symptoms and the type of laceration that she experienced. Even if the patient doesn't have bowel symptoms, typically with a three C or a fourth degree laceration, I would still do a rectal exam. Some women want to know if they have any symptoms of bowel disease. Some women want to know what's going on with their healing but are scared to look themselves. So often I find that a handheld mirror can be really helpful for patients who want to know more about their anatomy, but want to do that with someone who can explain what's going on with them and what is normal. And I find that as long as I go slow during the exam, explain what's gonna happen before I start and what I'm doing as I'm going along, patients typically tolerate this exam well and often state that it's not as bad as they thought it would be. So I think just thinking about what you would want if you were in that patient's position goes a long way to help them through this exam. And then you may provide some treatment on the spot based on your exam findings. So once your physical exam is complete, you're gonna go on to do some education for the patient. So she may have had some concerns that she brought at the beginning of the visit that you couldn't answer until you examined her. So now you want to address those issues. You're gonna educate her on what her tear was, how she's gonna care for her bottom, how she's gonna heal in the future. You can develop your own resources for patient education, but there are some great resources both from Oggs and iUGA that can show patients their anatomy and explain their tear. I find that these diagrams are really helpful for women. It helps them understand what happened or what their tear was. And then if they had an OAC, we talk about their risk factors for that OAC. What did they come into that delivery experiencing that may have caused that? Whether or not that risk factor will be persistent in their next pregnancy, and talk about any indications about how their future deliveries should go. We don't make firm recommendations at this point because typically women are still within two weeks from delivery. So there's a lot of information that could influence a future delivery that we don't know yet. So I typically do this in broad strokes. There are a few situations where we know that we would recommend C-section in the future, things like wound breakdown, fistula. But for most women, vaginal delivery is reasonable in the future. If there are a lot of things pending like fecal incontinence or some healing that I feel like we can't make a recommendation yet, I'll note that as well. And I summarize all of those things in the assessment and plan. That way in the future, if she returns for delivery counseling, all of that information is together in one place and can really facilitate future discussions. The other thing that's important is to communicate the plan of care to the obstetric team. So we're all used to sending our notes to the referring provider, but I send it to others as well. So I look back in the patient's chart who provided her obstetrics, her antepartum care, so her prenatal care. I also look at who was at her delivery. If there was a provider and a trainee and a midwife, I send the note to all of them. And I look at who her six week postpartum visit is scheduled with. And I send my note to all of those people because I think it's important, especially to have communication in general. But when it comes to this patient population, they often feel like they aren't being cared for appropriately or no one told them what to expect or no one knows what's really going on. And so for them to go to their next appointment and have that provider understand what's going on with them, I think is really important for the patient. The other benefit of this is it helps you establish a close relationship with the obstetric specialist and creates a dialogue for additional questions and concerns. Again, when I was in early in my practice with this clinic, I was worried that people were not gonna wanna get, keep getting all these notes from me to everybody who was involved. But I frequently get thank you notes all the time about providers being happy that they know what happened to the patient, especially trainees and especially hospitalists or laborists. They never see their patients again after they deliver often. And so I think for them understanding how patients do is valuable. So then moving on about resources to enhance patient experience is another thing that you wanna think about. Now, this is something that can come a little bit later. I don't think this is a critical first step to develop these things, because some of this, what you need to develop is gonna be informed by how your clinic runs and what you hear from your patients. So you may hear from patients that certain things are missing for them or that they wish they had known at a certain time. And so that's gonna help you design these things. So things to consider is one is pamphlets. Maybe you have just a very short pamphlet on your postpartum unit that is given to women who deliver to help familiarize them with the clinic, just so they know what is the phone number, why am I being sent here? Direct marketing and outreach within the community are good ways to increase awareness as well. You wanna publicize services by providing education to patients and also to providers. The other thing is that website can be really helpful. So anything that you're developing for pamphlets or publicity should all be on your website that explains the clinic. Because some patients, especially our obstetric patients are usually pretty young. They will all be looking online for some of this information. So if we fail to give it to them on the postpartum unit, then online is another way that they can find this information. So this I think is a less critical initial step that you might want to be informed about how your clinic is running before you build it. Another thing that I think is important early on is identifying support staff and other team members that are gonna be essential to running your clinic. So nursing support can be really helpful with patient triage. So I mentioned earlier, having a dedicated RN that does pre-appointment outreach is really important. And if a patient is referred from an outside institution, it can be really helpful. They can obtain records for you. They can help you schedule office visits and patient follow-up. And really help you manage your schedule of how these patients are being placed in the schedule. This type of care is also great to have, to share with an advanced practice provider. It can, especially if you end up with a high volume of patients, you may have difficulty seeing them all as quickly as you'd like to. And pairing with an advanced practice provider can be really helpful. So when your nurse screens patients who maybe have a less severe care or who are healing well and don't have any complaints, might be the ideal patient to see your advanced practice provider. Because those patients are less likely to have a concern that they're not seeing and those patients are less likely to have a concern that may potentially be surgical. So the APPs can evaluate patients who are less complicated and also follow up appropriate concerns as well. Pelvic floor physical therapy collaboration is really important as well. We know that most, if not all women with OAC and other postpartum pelvic floor concerns can benefit from physical therapy. So you wanna build a relationship with a physical therapist who's willing to be invested in this work with you. And that's another thing you wanna do early on. So when you're engaging leadership in your institution, meeting with obstetric providers to talk about what they feel is needed at your institution, you also wanna reach out to physical therapists and talk about their experience with this patient population, what they're comfortable with, when they're comfortable seeing the patient, how they feel about pelvic floor exercises before patients see them. So you wanna start that collaboration early on as well. Since most of us have a background in OBGYN, we're all well aware of the pelvic ultrasound resources available at each of our institutions, but that's something you wanna always be aware of. Different providers feel differently about what is the role of imaging in this patient population, but whatever you feel, ultimately some of these patients will need imaging, either their pelvic floor or the anal sphincter. So you wanna understand the resources available. I also find that collaboration with psychology, GI or colorectal surgery can be helpful as well as there is some overlap, especially you wanna have follow-ups set up for, a route of follow-up set up for patients who may have a positive depression screen. So another thing that's really important is to educate referring providers and individuals involved in care of these women. So this education is gonna be to multiple different groups. So attending physicians, not just our OBGYN colleagues, even though they're providing the bulk of obstetric care, you wanna have a group of people who are attending physicians who are attending OBGYNs, even though they're providing the bulk of obstetric care, you wanna remember also our family medicine colleagues also are doing obstetric care in some institutions. So you don't wanna forget about them. Trainees, midwives, advanced practice providers, nursing staff and physical therapists. So you wanna provide them initial education about the referrals and how to get patients to you, what patients you're looking to see, but you want that education to be ongoing as your clinic grows and changes. So when you change things, you educate people about the referral process or who you're seeing and how that changes. You may educate them about what you're finding in the clinic. I have, it's been my experience that many of the providers who refer to this clinic really want to know what you're learning and what your experiences are so that they can improve their own care. Also, if you identify gaps in care or ways to improve quality within your institution, you have an opportunity to share that with others. And I have found that people are really open to this. So reviewing some keys to success that I think are really important points in this spectrum of setting up your clinic, I think support from key leadership is essential. Without this, I don't think it's possible to be successful. So you want to, this should be the first step in your process, and you want to be well prepared for those meetings. And depending on how well you know your leadership, you may understand what they value and tailor your presentation around that. You want to build a referral system within your medical record. You want to automate as much of this as possible because we're dealing with very busy obstetric providers. And so these are people who don't have time to go back and remember and do a complex system. You want to try and streamline the process as much as possible and make it easy. You want to be using a team approach. So involving individuals at all steps of the process in your clinic as well and when providing patient care. Start early. Anything that you identify that needs to be done, I would just go ahead and work on it and not feel like that's a later step, except for developing some of those materials that I talked about. And you want to be flexible. Like I said, initially, I thought I was going to be just doing an OASI clinic. And then what I realized over time is that there are lots of other reasons patients need to be seen. So you want to be flexible when someone sends you a referral. I look at the indication on the referral, but I also read the patient's entire chart because sometimes there are things in there that can't be conveyed with an ICD code on a referral. So you want to understand. You want to be really flexible and open. It's also good in the beginning to be open to seeing as many patients as possible, especially if your leadership is worried that the viability of your clinic is questionable because there are not going to be enough patients for you to see. You want to be very open-minded because really, if you're trying to fill a gap in care, you want people to be able to tell you what that gap is and what they perceive the need is. And you want to pay attention to details and trends. Many of the things that I've taken on as quality projects from postpartum clinics are not things I necessarily expected. It was an opportunity because I see things that are uncommon frequently. I'm able to identify problems that might be lurking that no one else has a chance to notice. You want to be attentive to detail and trends and complications and what's actually happening in your clinic and be really open to change. Maybe your initial referral system just wasn't well-designed and needs to be redesigned. So you want to pay attention to any problems that patients describe to you with getting into your clinic, other frustrations or complications. But above all of this, I think the most important key to success in this clinic is communication. So I have found that you cannot over-communicate in this type of service line between telling providers how their patients are doing, asking questions, conveying information that you learn from patients in the clinic about workflow or other issues. It just can't be understated. So you want to communicate frequently with many people. And you want to think about engaging some of those larger groups on even maybe an annual basis. So if you have a midwife annual meeting, maybe you want to present at that sometimes or monthly meetings you want to present at. So you always want to let people know what's going on. And I found that that can be really helpful. So ultimately, this type of clinic with really careful planning gives you an opportunity to improve patient satisfaction and outcomes and to educate both patients and providers and to contribute to the growing body of evidence-based practice in this area where we need more evidence. Other things I think that can be helpful for you is knowing that there are a community of providers caring for these patients who have clinics similar to this one that I described. And reach out to us. I put my email address here, please reach out to me. Also our special interest group in AUGS is pelvic trauma, I'm sorry, pelvic floor birth injury I think it's called. I can't remember the exact name at the moment, but please join our group. We're trying to provide education resources for people starting this type of clinic. So I think those of us who are doing this type of work are really excited about it and want others who are also excited and invested to feel supported and able to create this type of clinic. So please reach out if you are interested in this. So that's all I have. Thank you for your attention and I'm happy to take any questions. Great, thank you so much. We have a couple of questions already. The first one is, have you encountered patients complaining about their obstetrician and wanting to sue him or her? And how do you sort of navigate that situation? Yeah, so I have definitely had patient complaints from how things went on labor and delivery. I have not had patients necessarily saying to me, like making threats to have lawsuits. I think most of these women who feel that maybe their care wasn't optimal feel really vulnerable and I think are looking for some guidance as to whether or not what happened to them was normal at all. And is it because something like, what happened? Did my doctor do something wrong? And so I think here we have to be very careful because I wasn't there. So I cannot really say whether or not I think what happened was or was not the right thing to do. For many women, especially with wound complications or breakdown, what I do is try and focus on rates of complications in the literature and that's wound complications are common after these types of lacerations, even if they had perfect care after delivery. And I think obstetric providers are often under a lot of pressure and generally are doing the best job that they can. And so I try not to make a commentary on the care that was provided on labor and delivery, but focus on what we can do to make them better. And I make sure not to speak ill of my obstetric colleagues. So I try and put it all into perspective. Many patients, even if they're doing well, might be concerned about how long it took to repair their laceration. And then it gives me an opportunity to explain to them that it takes a long time to do a good job and then that reassures them. And so I think for me, I have to also think about putting myself in the shoes of the obstetrician to explain that as well. But you want to be really careful not to ever point fingers at colleagues. Yeah. Yeah, that's great. There are a couple of questions about recommended resources, both for clinical care, which I know wasn't the focus of the talk, but also the patient outreach information and the pamphlets and things. And if any of that is available, and if so, where and what are your go-to sources? Yeah. So there definitely are resources available, but they're not a lot, unfortunately. So actually, RCOG, Royal Colleges OB-GYN, has excellent patient education resources, better than ACOG, unfortunately. So that's one place to look. The other place that you can find good resources is that many of us who have clinics have websites with patient information on them. So I started my clinic at USF this year. Prior to this, I was running a similar clinic in Cleveland, and Cleveland Clinic has a great website where we have a lot of patient information that can easily be used. And as I point out, the AUGS and iUGA websites have handouts for patients as well. But unfortunately, since things are sort of limited, you may eventually want to create some of your own literature for patients on what you want to communicate to them. But those are good places to start, current clinics, AUGS, iUGA, and RCOG. Great. Thank you. I had a question actually about billing and reimbursement for these visits. Have you run into issues as an OB-GYN trained FPMRS billing for these sort of subspecialty or specialty visits in the postpartum sort of global period? And if so, how do you navigate it? Yeah. Yeah, that's a great question. And I think it is commonly a concern of leadership of, is this visit going to get wrapped into the global package, and now we're giving a half a day of your clinic away every week? And that's why the referral system is so important, because I have found that as long as there's a consult ordered for the patient to see me, I have not had reimbursement issues with these consults. So I think that's why that referral process is so important, is you really need that consult order, not just for the patient to get to you, but you really need it for billing purposes. And you're billing as a consult, or you're billing as just like a new E&M level four or five, whatever, however you want to call it. Well, so it depends. So if there is a consult, then I bill for a consult. If a patient refers herself to see me, then I would bill her as a new or an established patient, depending whether or not she's been seen in my department, based on those billing rules. But most of the, almost all of these patients are referred to me, and so I bill them as a consult. That's good to know, and really reassuring, especially when you're trying to get buy-in from leadership. Yes. All right. There are a few other questions. One is about liability, and would there be increased liability for the provider at the peripartum clinic if the patient does end up suing? Are you at risk to be named in that lawsuit? So I'm thankful that so far I don't have any experience that I can directly drop on to answer this question, but I do think at least there is one paper that I listed earlier that did a review and actually showed that these types of clinics are linked to less litigation related to OASI. So I mean, I think anytime any of us sees a patient, there's a risk that we could be pulled into a lawsuit. So I think, you know, depending on someone's concern about that, that may mean that they are, maybe that they're not a good provider to want to really be invested in this type of clinic. It's something to consider, is this something you're really invested in? But I have not had that experience, but I think anyone who provides care to a patient for a complication potentially can be named in a lawsuit. But I have not had that experience, and it's not reflected in the literature. So I don't see that as something that deters me. Great. The last two questions are also about sort of clinical, providing clinical care. One is, what are your thoughts on vaginal estrogen for lactational atrophy in women with OASIS? That's a great question. So I think that the estrogen is a totally safe and reasonable thing to use. I don't use it universally. I use it more if there's a concern about atrophy or something like that, just because many of these women, right, most women with severe lacerations are new moms, so they've had their first baby, they're trying to figure that out, they're pretty overwhelmed. And so I try not to add things unless I can see a direct benefit for the patient. But I think it can be useful, yes. Great. And then the last question is, how do you decide who, when endoanal ultrasound is indicated versus just a simple digital rectal exam? Yeah, that's a good question. I think there are different algorithms out there of how people make these decisions. And so you kind of, I think you have to take the literature and make some of your own decisions about resources at your institution and who's doing the ultrasounds of how you're going to operationalize that. For me, if a woman has a history of an OAC, my digital rectal exam is normal and she's continent, and I don't have any reason to believe that she has a defect that needs to be addressed, I tend not to do it. I might be more likely to do it if I think it's going to impact my care. So if I believe a woman has a residual anal sphincter defect that needs to be addressed or might be a reason for symptoms she's having and warrants surgical intervention potentially, I would do the ultrasound. So it's a little bit of a vague answer, but there are definitely algorithms out there that can help you decide that. I don't necessarily recommend doing this in every patient because you have to make sure you have the referral system or the resources in place for those ultrasounds to actually be done. And I don't currently have that kind of support for that much volume at my institution. And so for me, if I'm going to do that many ultrasounds, I prefer it to happen in my clinic. So, and I don't have resources for that at this time. So I try to really restrict that more to when I think it's going to impact management. Great. There was another question about whether or not you think it would be reasonable for a generalist OBGYN with a special interest in this topic to run such a clinic? Yeah, I do think that's reasonable, but we need to make sure that that person has good support. So there are going to be certain things that an FPMRS specialist has experience in that will improve care for these patients that perhaps an obstetric specialist doesn't, in terms of, you know, wound breakdown, reconstruction, those kinds of things. So I think if there is a generalist who is interested in this, my recommendation to them would be to try and collaborate with an FPMRS specialist to work together to run this type of clinic. In the same way, you might run this type of clinic with an advanced practice provider. You know, that person certainly isn't equipped to operate on patients. And so I think it could be successful as a team approach. Also, if there are limited resources at an institution and there is no FPMRS provider, then perhaps that person could collaborate with someone outside their institution, at least to provide some support in terms of certain clinical situations. Great. And then just one other question about sort of your schedule for seeing patients and follow-up. Do you, how often do you see patients? Is it individualized or is it standard after your initial two-week postpartum visit? What do you typically recommend? So I think this person's asking about timing of follow-up after the initial visit. So for patients who have OAC, I tend to try, or any delivery complication, I try to see them within two weeks of delivery. And then the next follow-up, it depends on what's going on with them. Say the patient had a mild laceration, like a 3A, she's healing well, she has no complaints. I often will refer her back to her OBGYN for follow-up care and only come see me if she has issues. If she has anal incontinence and I'm sending her to physical therapy, or if she's having a wound healing issue or something else like that, or I'm treating granulations issue, I often will see them back. I won't just send them back to their regular OBGYN. So it depends what the issues are and also what the patient wants. And then depending what I'm doing, if I'm waiting for a small wound breakdown to heal, initially I saw those patients more often, maybe every week or every other week. But that process can take a long time. So those patients I meet every two weeks, if we're sending them to physical therapy for pain, that might be an even longer interval, right? Give them a few months to work with PT. So a lot of it is driven by what you're doing, what you're trying to follow up, and what's important to the patient. If the patient perceives something to be really urgent and bothersome, you might want to see her a little sooner than the next patient. So it really varies. Perfect. Perfect. That was the last question, unless anyone has any others. Feel free to pop them in the chat. But otherwise, on behalf of AUGS, I'd like to thank Dr. Probst and everyone for joining us today. Be sure to register for our upcoming webinars. December 21st is Tis the Season for Good Laxation, how to more effectively treat individuals with chronic constipation. And January 18th is Simulation in FPMRS Education, and this will be put on by a team of faculty from Emory University. And there's lots of comments coming into the chat about how great this talk was. So thank you so much, Dr. Probst. Thank you. Thanks for having me.

peripartum pelvic floor disorders clinic

logistics

support from leadership

referral system

multidisciplinary team

flexibility

communication

ongoing education

patient benefits