Pelvic Health Follow-Up Issues List

"Notes transcribed with an AI scribe - patient provided verbal consent before the session began"

Patient Information

• Chloe Davies, Age: 34 years and 6 months, Female
• Occupation: Primary school teacher
• Physical Activity: Brisk walking 30 mins 4x/week, clinical Pilates 1x/week. Keen to return to jogging.
• Present: Attended with 4-month-old infant (Liam).
• Upcoming review with Dr. S. Patel (Gynaecologist) on 14/05/2026.

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Subjective

• Reason for visit: Follow-up for postpartum stress urinary incontinence (SUI) and mild pelvic organ prolapse (POP) symptoms.
• Reports 50% improvement in SUI episodes since last session 3 weeks ago; vaginal heaviness is now intermittent rather than daily.
• Good adherence to HEP; completing pelvic floor muscle training (PFMT) 2x/day (missed occasional evening sets due to fatigue). Consistently using 'The Knack' prior to coughing and lifting.
• Bladder Symptoms: Voiding 6–7x/day, nocturia 1x (waking with infant). SUI 1x/week with unguarded sneeze (previously daily). No urgency or urge incontinence. Using 1x panty liner daily for confidence, mostly dry. Normal flow and complete emptying.
• Bowel Symptoms: Bowels open daily, Bristol Stool Type 3–4. Mild straining if fluid intake drops below 2 L/day. No faecal or flatal incontinence. Uses footstool routinely.
• Prolapse Symptoms: Mild vaginal dragging/heaviness at the end of the day if standing > 4 hours at work or after carrying infant in capsule. Resolves overnight.
• Sexual Symptoms: Resumed penetrative intercourse last week; mild superficial dyspareunia on initial entry, resolved with silicone-based lubricant.
• Pelvic USS (02/04/2026): Normal postpartum uterus and ovaries, post-void residual volume 15 mL.

Patient Goals

• Short-term goal: Cease daily liner use and achieve 100% continence with coughing/sneezing within 4 weeks.
• Long-term goal: Return to 5 km continuous running without SUI or vaginal heaviness within 12 weeks.
• Progressing well; short-term goal nearly achieved, building foundational PFM endurance for return-to-run protocol.

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Objective

PFM Assessment

• Informed verbal consent obtained for internal vaginal examination; chaperone declined.
• Assessed in crook lying.
• GH+PB: 3.5 cm + 3.0 cm at rest.
• Prolapse: Grade 1 anterior vaginal wall descent on Valsalva (remains well above hymenal remnant). No posterior or apical descent noted.
• Tone: Normal normotonic resting tone bilaterally; no tenderness on palpation of levator ani or obturator internus.
• Strength: Modified Oxford Scale 4/5 (good lift and squeeze).
• Endurance: 8 sec hold x 8 reps before fatigue/recruitment of gluteals.
• Fast twitch: 10 brisk contractions with complete relaxation between reps.
• Relaxation: Complete and rapid return to baseline resting tone post-contraction.
• Effective cranio-ventral lift observed during cough ('The Knack').

MSK Assessment

• Posture: Mild thoracic kyphosis and anterior pelvic tilt in standing.
• Lumbar Spine ROM: Full, pain-free flexion, extension, and lateral flexion.
• Inter-recti distance (IRD): 1.5 finger-widths at umbilicus, 1.0 finger-width 2 cm above; good linea alba tension generated on deep abdominal activation (transversus abdominis).
• Functional: Single leg squat x 10 each side shows mild left hip drop; no breath-holding or downward pelvic floorbulging observed.

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Action Taken

1. Postpartum Stress Urinary Incontinence

• Progressed PFMT in standing; practiced coordinated PFM pre-contraction with mini-squats and lunges. // Good technique, able to maintain sub-maximal PFM hold during functional movements without Valsalva.
• Discussed progressive loading principles and criteria required prior to commencing return-to-run program.

2. Grade 1 Cystocele / Vaginal Heaviness

• Instructed on hypopressive breathing and restorative pelvic positioning (supported bridge pose) for end-of-day symptom relief. // Reported immediate reduction in pelvic pressure after 2 mins in modified inverted position.
• Advised to minimise carrying baby in heavy capsule; encouraged use of ergonomic baby carrier or pram. Reinforced importance of maintaining soft stools via 2.5 L daily fluid intake.

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Evaluation: Improving as expected; PFM strength increased from 3/5 to 4/5 and endurance from 5 sec to 8 sec over the past 3 weeks.

Home Program:

1. PFMT in standing: 8 sec hold at 80% MVC x 8 reps, followed by 10 fast contractions, 2x/day.
2. Functional integration: Sit-to-stand and split squats (2 sets of 10) with coordinated expiratory PFM lift, 1x/day.
3. Restorative decompression: Pelvis elevated on pillow for 5–10 mins after work.

Handouts/Leaflets: Emailed "Return to Running Postpartum Guidelines" PDF and updated exercise program via Physitrack.

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Plan

• Review: 4 weeks (18/05/2026) for pre-running impact assessment.
• Letter: Progress update letter to be sent to referring GP, Dr. M. Roberts, and copy to Dr. S. Patel.
• Ongoing plan:
  • Progress to high-load, impact-readiness PFM training (bounding, hopping) at next visit if endurance reaches 10 sec x 10 reps.
  • Nil additional referrals required; patient already booked for routine gynaecology review. Ensure silicone lubricant continued for intercourse.