I have been interviewing parents and professionals about what it’s like to have a baby during the pandemic. Recently I interviewed Dr. Romy Havard (she/her) of Peregrine Physical Therapy. Dr. Havard provides the East Bay Area, CA with orthopedic, prenatal, postpartum, pelvic floor, and wellness services. She went to UC Berkeley for undergraduate and later attended the UCSF/SFSU Joint Graduate Program in Physical Therapy with MS and DPT degrees. She is also Board Certified in the Orthopedic Section (OCS).
While she uses a broad variety of skills, she is most influenced by the Institute of Physical Art and utilizes functional manual therapy for optimal efficiency. She is also enthusiastic to incorporate concepts from Herman Wallace in pelvic health and contribute to advocacy for postpartum, incontinence, and transgender care.
Here is what we talked about (all emphasis mine):
Me: What are some of the challenges that you have experienced serving families during the pandemic?
Dr. Havard:
For the past 6 months, a lot of the major hospitals have ceased doing in person care for the majority of prenatal appointments. Unless you have dire deliveries, even the one postpartum follow-up is done online with OBGYN. So women who are delivering have little to no before or after care according to ACOG (American College of Obstetricians and Gynecologists) standards. Normally you have all of your check-ups. Everything except the ultrasound and the diabetes test is done online unless you have preeclampsia. New moms are particularly isolated. Some are traumatized. Resources are few. Normally you would meet other moms in a mom group. They don’t have that extra help. They are wondering if their pain and lack of function are normal. I’ve been extraordinarily busy because I’m doing in-person visits. People are driving 45 minutes to see me because they could not be seen closer to home. I often have women who cry through their appointments. I have some days where half of my women are crying through their appointments.
Two years ago ACOG had an article that they released about how postpartum care in the US is substandard. That one appointment postpartum is not enough. But they didn’t really define what better care would be. Pelvic physical therapy should be done with all our moms. And even that isn’t being done.
Me: What are some of the frustrations that you have experienced serving families during the pandemic?
Dr. Havard:
I’m outside the electronic medical system. Smaller offices are easy. I fax them and they get back to me. If I think that this patient needs something specific, those offices are easy to deal with. But most of my patients come from giant Kaiser or giant Sutter. I write them. I fax them. It’s very hard to get them to get the patient what they need. I’m asking for things that are out of my scope of practice. Their lack of participation is alarming. These are things that I can’t do for them. Way more so during the pandemic. A lot of physicians doing Telehealth are doing it from home. If they are never going into the office. If no one is scanning notes and they can’t get to it… I’m not sure what is happening there. It’s even harder to contact doctors. I’m still in the medical system. I still need medical and surgical consultations from doctors. These people are already being seen by these people. I don’t know what’s going on over there. I don’t know if they have had a COVID breakout or what they are going through, but there’s only so many ways that I can send letters through.
Me: What are your fears for new parents at this time?
Dr. Havard:
I just don’t want something to be missed. In pelvic therapy, it’s not life or death, but there are issues around it that I worry that women not pursuing more medical care for things are going to make things worse later. I’m getting more severe diagnoses than I used to as well. I’m having more fecal incontinence patients than I used to and that’s alarming. They should be having consultations with colorectal surgeons, but these are considered non-essential services. I am worrying about their fecal incontinence long-term. I’m trying to be supportive and educate but not be triggering. I want moms to have all the tools, but I don’t want to say “and you need to do this now.” It’s easier when you are treating within a group of integrated professionals. I am not meant to be doing PT on my own with patients. They should be having medical support, nutritional support, GI support.
Me: What do you wish that new parents knew?
Dr. Havard:
New moms should seek care early and really consider preventative strategies. The more you can do to avoid more acute and serious issues, the better you will do and the more options you will have. Pelvic physical therapy is inseparable from the postpartum experience and should be part of postpartum care. Especially for moms who may not even get physicians to look at their pelvic tears. At 3 months, maybe you want to go back to having sex. At 6 months, you want to go back to running.
… The women who are crying in my office are months from birth and they have been waiting for things to fix themselves. If they had started earlier, it would be a small thing. It wouldn’t interfere in their marriage. It wouldn’t make them start to wonder if they could have another kid. There are lots of difficult thoughts.
OBGYN postpartum just wants to make sure your cervix is closed, you’ve passed the placenta, that you don’t have infections, that you have contraception. They are not addressing the pelvic floor. If you are leaking at 6 weeks, that’s not normal. OBGYNs take care of general health, deliveries, general wellness, infection, venereal disease, contraception. Dealing with preventable testing like pap smears. They are not really treating leaking, prolapse, and pelvic pain issues. Some of them are so helpful, quick to get back to patients.
On one hand, just doing postpartum care is a little after the fact. Currently in the US and Britain 85% of women will have a perineal tear, 75% will require sutures. I have one visit during pregnancy to decrease their chance of injury in delivery. It’s not the same as childbirth education. It’s just things that moms can do to decrease their injury. OBGYNs don’t necessarily work from the position of the mother ergonomics. It’s more about the baby. Working on the preventative side is great. I do recommend a visit with pelvic physical therapist before or during pregnancy week 30. You need to start doing the exercises I prescribe daily easily 6-8 weeks before delivery for them to get maximal benefit. I just had a mom who went through it and had no tearing. This is where we need to move - to not just care for tears postpartum. In Australia a lot of people have a pelvic PT during labor so mom doesn’t get hurt. Pelvic physical therapists in the United States don’t have hospital privileges to attend labor and delivery. The least I can do is to do education with moms about taking care of you to avoid tearing, prolapse, urine prolapse, etc. and sometimes c-section.
Me: If you were to look ahead to the future and everything amazing that you can imagine comes true, what would that look like?
Dr. Havard:
In Britain about 2 years ago they voted to add pelvic physical therapy to the standard of practice to be included in national health care. Now even low and middle income women can have this as part of postpartum recovery. Our mortality rate is equal to Mexico. A lot of the moms I see are also more into progressive prevention. I recommend if I was doing bare minimum for someone who is doing great otherwise is:
- one visit during second trimester in case you need a C-section or to minimize injury
- one visit at 6-8 weeks.
- Another visit ideally around 3-4 months. There’s a big hormonal shift then and a lot of women their repairs get worse at 3-4 months. 1 of 9 births will have a Hashimoto event.
- A visit around 6 months for women if they’re doing great. If they are fine with walking or jogging, a 6 month visit may be enough.
- For cross fit or heavy runners, another visit at 12 months as well.
I just want to send a big shout out to Dr. Havard and thank her for sharing her wisdom and experience. She serves in the East Bay in California. You can find her at https://peregrinept.org.
