Advanced maternal age (AMA) is typically defined as pregnancy in women aged 35 years or older. Being of advanced maternal age doesn’t necessarily make postpartum recovery harder. However, it can be associated with factors that may impact the trajectory of the recovery process.

Today, let’s explore a question that I often encounter when teaching the peripartum series (Pregnancy Rehabilitation and Postpartum Rehabilitation): Does Pelvic floor function and recovery look different in women of advanced maternal age compared to younger birth parents?

In a 2024 study by Swenson et al.,¹ their objective was to determine the differences, by maternal age, at first vaginal birth, in genital hiatus (GH) from late pregnancy through one year postpartum. They were investigating this question because older maternal age at the time of first vaginal birth can increase the risk for pelvic organ prolapse (POP). Genital hiatus (GH) enlargement seems to precipitate POP. (A larger measurement of the levator hiatus is associated with POP.) They offer a possible explanation for this increased POP risk with AMA, suggesting that older age may impair the recovery of the connective tissue and pelvic floor muscles (PFMs) that help maintain normal GH closure. This study included POP-Q exams in the third trimester, 8 weeks postpartum, and 1 year postpartum. In this study, they defined AMA as pregnancy in women aged 33 years or older, and there were 593 participants with a mean age of 28.8 years old.

What they found was that there was no significant difference in GH between age groups in the third trimester or at 8 weeks postpartum; however, at one year postpartum, the GH was significantly larger in the older group. These authors concluded that “ongoing PF changes continue past the traditional 6-week postpartum period and that older women may follow an impaired recovery trajectory that could lead to anatomic POP.”

How interesting! This conclusion suggests that the increase in size of the GH is happening during the first year postpartum, so this seems like an optimal time to participate in pelvic floor therapy.

The authors further suggest that identifying postpartum women in an impaired recovery trajectory could advance efforts to develop preventative strategies and early interventions. A study like this may help us advocate for women of “AMA” and the strong need for early, routine pelvic rehab to perhaps prevent or minimize POP.

In an observational prospective study in 2013, Yoshida et al.², aimed to show differences in temporal recovery of pelvic floor function within the first 6 months postpartum between women having their first birth at AMA and those having their first birth at a younger age. Following vaginal birth at 6 weeks, 3 months, and 6 months, 17 women were studied. Urinary incontinence was assessed by the International Consultation on Incontinence Questionnaire Short Form, and PFM function was assessed by the anteroposterior diameter of the levator hiatus using transperineal ultrasound. They found that more of the women who reported urinary incontinence were of the advanced maternal age group, and that the diameter of the levator hiatus, at rest, was larger in the AMA group compared to the younger group. Therefore, they concluded that recovery of pelvic floor function following birth may be delayed in women of AMA.

This study was older and smaller than the previous one we looked at by Swenson et al. However, both seem to echo a similar message that first-time birthers of advanced maternal age may have a different recovery trajectory than someone who births for the first time at a younger age.

Let’s look at one more study regarding interventions. In a randomized controlled trial in 2024, by Huang et al.³, they aimed to investigate the efficacy of postpartum nursing guidance in the treatment of early pelvic floor dysfunction (PFD). This study had 146 women of AMA, divided into control and intervention groups. Both groups were given routine pelvic floor rehabilitation treatment, including low-frequency estim, individualized biofeedback, and postpartum rehabilitation guidance with instruction on PF rehab to enhance their self-care awareness and self-management skills for 30 minutes, 2x/week for 15 sessions over 3 months. In addition to the routine pelvic floor rehabilitation treatment, the experimental group was given “postpartum nursing guidance, “which was an individualized program consisting of health education tailored to the individual’s education levels/background (consisting of visual aids, images, brochures, one-on-one counseling sessions). They also had psychological counseling, progressive and more specific PF muscle training (contracting PFM’s on exhale and relaxing on inhale, integrating use of PFM’s with daily activities, PFM contractions were progressed by position, duration over time with specificity, from 5 minutes to 15-25 minutes per day and 2-3x/day).

Lastly, the experimental group had regular follow-up visits. To summarize, the experimental group had more of a comprehensive, individualized, wholistic approach to treatment compared to the controls. In the study, they compared the two groups before and after the interventions for PFM strength, urinary incontinence, prolapse, and nursing satisfaction (satisfaction with their care). There was no statistical significance between the two groups before the interventions; however, 3 months after the intervention, the experimental group had significantly lower incidence of urinary incontinence & POP and significantly higher PFM strength and higher nursing satisfaction scores than the control group.

After synthesizing these three articles, let’s think about what we would change with our rehabilitation approach for patients of advanced maternal age. 

• -It may be helpful to identify the patients who are 35 and over following their first birth for prevention and treatment of PFD.
• -We should be educating perinatal providers in our area and advocating PF rehabilitation for those who have birthed, but particularly those over 35.
• -We should advocate for early PF rehab, hopefully before 1 year postpartum.
• -When setting goals and expectations for recovery, recognize that patients of advanced maternal age may need longer.
• -The individualization approach to PFM interventions seems to be superior to general advice.
• -A wholistic treatment or comprehensive/team approach may lead to better outcomes.

Hopefully, this challenges you to think a little deeper when treating patients of advanced maternal age!

Whether you're currently supporting patients through their pregnancy journey or guiding them through recovery after birth, Herman & Wallace’s Peripartum Series offers essential tools for evidence-based, compassionate care. Start with Postpartum Rehabilitation on August 16-17 to strengthen your foundation in pelvic floor recovery and core reactivation. Then, deepen your clinical skill set by joining Pregnancy Rehabilitation on September 13-14, where you’ll gain strategies to support prenatal adaptations, manage musculoskeletal pain, and optimize function throughout pregnancy.

Together, these courses provide a comprehensive path for clinicians committed to advancing care for the perinatal population.

References:

1. Swenson, C. W., Hendrickson, W. K., Allshouse, A. A., & Nygaard, I. E. (2024). Older maternal age at first vaginal delivery is associated with increased genital hiatus size at 1 year postpartum. American Journal of Obstetrics & Gynecology, 230(6), e110-e112.
2. Yoshida, M., Murayama, R., Nakata, M., Haruna, M., Matsuzaki, M., Shiraishi, M., & Sanada, H. (2013). Pelvic floor function and advanced maternal age at first vaginal delivery. Open Journal of Obstetrics and Gynecology, 3(4), 28-34.
3. Huang, Q., Tang, J., Zeng, D., Zhang, Y., & Ying, T. (2024). The effect of postpartum nursing guidance on early pelvic floor dysfunction recovery in women of advanced maternal age: a randomized controlled trial. Frontiers in Medicine, 11, 1397258.

AUTHOR BIO
Rachel Kilgore, DPT, OCS, COMT, PRPC

Rachel Kilgore, DPT, OCS, COMT, PRPC, PPCES (she/her) graduated from Central Washington University with a Bachelor of Science (BS) in exercise science and a minor in nutrition in 2004 where she also captained the collegiate soccer team. Rachel completed her Doctor of Physical Therapy (DPT) at University of Washington in 2007. She has worked in out patient orthopedics and pelvic health since 2007. She furthered her physical therapy training earning Certified Orthopedic Manual Therapist (COMT), Physical Therapy Board-Certified Specialist in Orthopedics (OCS), and Pelvic Rehabilitation Practitioner Certification (PRPC). She is a member of the American Physical Therapy Association (APTA), Section of Orthopedics and Section of Women’s Health, and the Physical Therapy Association of Washington (PTWA).

Currently, Rachel practices in Seattle at Flow Rehab in the Freemont Neighborhood with Holly Tanner and Jake Bartholomy. Her patient care focuses on orthopedics, female athletes, and women’s health conditions for bladder & bowel dysfunctions, pelvic, pain, pregnancy and post-partum issues. Since giving birth to her daughter in 2016, Rachel has held a special place in her heart to treat and encourage new mothers, helping them to achieve their health and fitness goals. She enjoys working with many of the local mother’s fitness groups and neighborhood peripartum practitioners.

In her free time Rachel enjoys cheering on her local Seattle sports teams the Seahawks, the Sounders, and the Husky Football team with her friends and family. She loves living in the Northwest and enjoying all it has to offer outdoors with hiking, running, cycling, and playing soccer.

I have always enjoyed working with the peripartum population. However, the longer I worked in pelvic rehabilitation the more I heard the same story over and over when interviewing patients. For example, when working with a patient with urinary incontinence or prolapse, I would say: “when did this start” and some of my elderly patients would laugh and say “when Johnny was born” and I would say “how old is Johnny” they would reply “40!” Many of the pelvic patients I was treating had symptoms originating around the time of childbirth and they had been suffering for decades. So, I figured, let’s get to the root of the problem and focus on earlier intervention.    

What is the root of the problem? In my opinion, it is the lack of postpartum care. Pregnant patients are often inundated with birth education programs and information about pregnancy and childbirth. Additionally, there is a battery of prenatal visits, prenatal testing, and preparations for birth. All of which are wonderful to help prepare for birth. Conversely, the resources and guidance to help with physiological and musculoskeletal healing postpartum are lacking. Patients are counseled about serious signs and symptoms, but clear guidance to help to return to daily functional activities including recreation and exercise is often not provided. As musculoskeletal and exercises experts we are in a wonderful position to help patients reduce pain and improve function following the birth of a child.

Prior to 2018, the first post-partum checkup was six weeks following birth. Barring any severe problems, this was often the last contact with a medical provider for the parent. Patients were not provided specific guidance on how to return to daily activities, let alone higher-level activities such as running, exercising, and/or lifting weights.

In 2018, the American College of Obstetrics and Gynecology (ACOG) revised its guidelines, which now support earlier and more frequent postpartum visits. It is recommended that the first contact between patient and obstetric care provider occur in the first three weeks following birth and that subsequent visits are scheduled as needed in an ongoing fashion¹. This is important, as many consider the patient is still healing from birth up to 12 weeks (definitions vary). Depending on their knowledge and experience, a patient may not immediately realize they have a musculoskeletal problem. A new parent is busy adapting to their role as a care provider and may not be thinking about themselves. Additionally, they may not know what “normal” is for their body postpartum, including vaginal, abdominals, and/or bowel, and bladder functions. For example, the patient may be experiencing urinary incontinence (UI) which they “think” is normal postpartum, therefore, they may not bring it up to their provider. Patients often seek advice from family and friends who may even joke about peeing their pants when they sneeze or laugh or play with their children. Urinary incontinence is not ever “normal”, however, is it common in the postpartum period. Availability of vetted resources and a relationship with a healthcare provider are essential to cure these misconceptions.       

According to a systematic review, the prevalence of urinary incontinence is 33% at three months postpartum² and remains at 29% four years postpartum³. This means about one-third of women have urinary incontinence postpartum and remain that way without intervention. We also know the prevalence of urinary incontinence is strongly related to increasing age and underreported. This example highlights a common misconception: pelvic dysfunction is a normal part of the after-birth stage. However, with intervention, these problems can be alleviated, and we can improve the quality of life for these patients. 

According to the American College of Physicians (ACP) clinical practice guidelines for non-surgical management of UI there is high-quality evidence that strongly recommends pelvic floor muscle training as the first-line treatment for stress incontinence.⁴

So why isn’t pelvic assessment and rehabilitation recommended for all people who birth in our country? In several European countries, pelvic rehab is standard postpartum care for anyone who births. Over the last two decades, I do see more postpartum patients referred for rehabilitation for their musculoskeletal impairments. However, I still think we need more skilled providers assisting these patients and spreading the word about the interventions rehabilitation professionals provide. These can range from common orthopedic complaints (e.g neck or back pain from repetitive baby care) to specific bladder and/or bowel dysfunction, such as leakage and/or constipation, abdominal separation (Diastasis Rectus Abdominus-DRA), prolapse, pelvic pain, perineal tearing, and/or pain with intercourse.    

When developing this four-course postpartum series, I wanted rehabilitation providers to have more advanced skills to provide examination and treatment to this special population. This includes techniques to assess and treat the abdominals and pelvis, as these areas are physiologically impacted by pregnancy and birth over a relatively short amount of time. To effectively treat this population, one needs to be familiar with physiological changes from pregnancy, and stages of labor and birth to understand the journey of your patient. There is so much we can do to help these patients over a range of complaints, from acute breast and perineal care to DRA and pelvic dysfunctions.  As with any special population, postpartum patients have unique red flags and concerns to monitor, and due to our more frequent patient contact, it is imperative to be proficient in screening for these conditions. These topics and more are included in the course series. 

I am grateful and appreciative of this collaboration between Herman & Wallace and Medbridge to provide a platform for clinicians to progress their knowledge. Hopefully, this improves access to postpartum care and increases referrals for rehabilitation services to improve the function and quality of life for parents. Together we can reduce chronic impairments stemming from the childbirth period.

Resources:

1. Accessed on 5/9/2022: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/optimizing-postpartum-care
2. Thom, D. H., & Rortveit, G. (2010). Prevalence of postpartum urinary incontinence: a systematic review. Acta obstetricia et gynecologica Scandinavica, 89(12), 1511-1522.
3. Gartland, D., MacArthur, C., Woolhouse, H., McDonald, E., & Brown, S. J. (2016). Frequency, severity and risk factors for urinary and faecal incontinence at 4 years postpartum: a prospective cohort. BJOG: An International Journal of Obstetrics & Gynaecology, 123(7), 1203-1211.

4. Qaseem, A., Dallas, P., Forciea, M. A., Starkey, M., Denberg, T. D., Shekelle, P., & Clinical Guidelines Committee of the American College of Physicians*. (2014). Nonsurgical management of urinary incontinence in women: a clinical practice guideline from the American College of Physicians. Annals of internal medicine, 161(6), 429-440.

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