Ever Since I Had My Baby

by Roger Goldberg

  In memory of Sara Distenfield

  Acknowledgments

  I first conceived of this book several years ago, during an early-evening drive through the Arizona desert, while on a short break from residency training in Boston. Having delivered a departmental grand-rounds lecture entitled “Childbirth and the Pelvic Floor” earlier that week, I was still feeling energized by the enthusiastic response of the doctors, nurses, and midwives in attendance. Yet as I drove, it came to me that women outside the medical community have had little or no exposure to the issues so essential to their physical well-being. Shouldn’t everyone be familiar with these remarkably common postreproductive problems and their causes? Shouldn’t women be better informed about making the most sensible decisions during pregnancy and delivery, and about the debates taking place over birthing choices? Aren’t they entitled to know the best strategies for prevention and finding treatment for problems? Clearly, these were topics warranting debate not only among doctors but also among their patients. This was a book, I realized, truly waiting to be written. I pulled over at the next exit, pinned a napkin against the steering wheel, and scribbled my first few lines. Since then, the support and enthusiasm of numerous individuals have enabled those early ideas to reach the bookshelves.

  I am grateful to have a truly remarkable publishing team. Dorian Karchmar, from Lowenstein Associates Literary Agency, embraced this book right from the start, shared my enthusiasm, and was invaluable in helping to shape my proposal with her sharp focus and skilled editing. I am indebted to Betsy Rapoport, who acquired the book for Three Rivers Press, recognized the importance of its subject matter, and understood its potential audience. I owe countless thanks to Caroline Sincerbeaux, my editor at Three Rivers Press, for her great talent and tireless efforts to create an accessible, user-friendly guide for women of all ages. Her editing skills were invaluable through the revision and shaping process. Lauren Shavell from Medical Imagery produced the book’s vivid and original illustrations, and I thank her for providing a high level of artistic talent while approaching this project with energy and creativity. Thanks also to Brad Herzog, a good friend and great author, for reviewing the early manuscript and offering his valuable advice.

  On the professional front, I would especially like to thank my colleague and mentor Dr. Peter Sand, a recognized leader in urogynecology and reconstructive pelvic surgery. The clinical material in the latter chapters of this book is in no small way a reflection of Dr. Sand’s guidance and renowned teaching skills. Thanks are due also to Dr. Patrick Culligan, of the Urogynecology Associates of Louisville, for his valuable advice at several stages. I am indebted to all others with whom I have worked at the Evanston Continence Center, with special thanks to Karen Sasso and Dr. Sumana Koduri for their help during my first few years.

  My mentors in the Department of Obstetrics and Gynecology at Beth Israel Deaconess Medical Center in Boston are too numerous to mention, but I owe special gratitude to Dr. Benjamin Sachs and Dr. Henry Klapholz for the direction and training they provided during my residency. Thanks, as well, to Dr. Toni Golen, an obstetrician-gynecologist also at Boston’s Beth Israel, for a close and insightful reading of my early manuscript amid her busy schedule. I am deeply grateful to many other physicians and nurses at “The B.I.” who imparted their high professional standards and their compassion for the patients.

  Robert and Anita Goldberg, your influence on this project cannot be measured. Above and beyond your constant guidance and unwavering values, you made this book possible by instilling a few specific literary traits: a love for writing, a discipline for editing, and the desire to take creative chances. For all of that and much more, I love you both. To Anna and Tony Nocera, world’s greatest in-laws: now that this book is finally on the shelves, we’re overdue for a big, long Sunday feast.

  Last and most important, to Elena, my wife, without whom this book simply could not have happened. Her patience and encouragement fueled the early mornings and weekends I devoted to this book. She shared my passion from the start and contributed to the end result in countless invaluable ways—as an editor, an adviser, and an inspiration. As in every other aspect of my life, our love has made it all worthwhile.

  Contents

  Preface: Beyond the Labor Room and After the Push

  INTRODUCING A LONG-OVERDUE CHAPTER IN WOMEN’S HEALTH CARE

  PART 1

  “WHAT’S HAPPENED TO ME DOWN THERE?”

  THE PELVIC FLOOR, CHILDBIRTH, AND PROBLEMS THAT ARISE

  1. Recognizing Your Postreproductive Problem

  INCONTINENCE, PROLAPSE, SEXUAL DYSFUNCTION, AND OTHER COMMONLY OVERLOOKED CONDITIONS

  2. Introducing the Pelvic Floor

  ANATOMY, FUNCTION, AND PHYSICAL CHALLENGES

  3. The Pelvic Floor After Childbirth

  INJURIES AND ANATOMIC CHANGES AND THE OBSTETRICAL EVENTS THAT CAN CAUSE THEM

  PART 2

  PREVENTIVE OBSTETRICS

  A NEW OUTLOOK ON PREGNANCY AND CHILDBIRTH TO PROTECT

  THE PELVIC FLOOR AND PREVENT PROBLEMS BEFORE THEY ARISE

  4. Preparing for Your Due Date

  WHAT YOU CAN DO DURING PREGNANCY TO MINIMIZE PELVIC STRAIN

  5. Learning How to Labor

  EXPLORING YOUR OPTIONS FOR STYLES, POSITIONS, AND TECHNIQUES

  6. Cesareans, Forceps, Epidurals, Etc.

  KEY OBSTETRICAL INTERVENTIONS AND THEIR POTENTIAL PHYSICAL EFFECTS

  7. After Delivery

  HOW TO MOST FULLY HEAL AND PREVENT PELVIC-FLOOR PROBLEMS DURING THE POSTPARTUM PERIOD AND BEYOND

  PART 3

  FINDING RELIEF FROM URINARY INCONTINENCE,

  PELVIC PROLAPSE, ANAL INCONTINENCE, AND SEXUAL DYSFUNCTION

  THE WIDE WORLD OF SOLUTIONS, FROM SIMPLE HOME REMEDIES

  TO THE DOCTOR’S OFFICE AND OPERATING ROOM

  8. Urinary Incontinence

  UNDERSTANDING YOUR LEAKAGE AND RESTORING CONTROL USING HEALTHY HABITS, SIMPLE TIPS, AND HIGH-TECH THERAPY IN THE DOCTOR’S OFFICE AND OPERATING ROOM

  9. Pelvic Prolapse

  BULGING, DROPPING, AND FALLING OUT: CAUSES, SYMPTOMS AND TREATMENTS

  10.Bowel Problems and Anal Incontinence

  EXPLANATIONS AND REMEDIES FOR A NEGLECTED FEMALE PROBLEM

  11.Sex After Childbirth and Beyond

  REGAINING SATISFACTION, SENSATION, AND SELF-CONFIDENCE

  PART 4

  YOUR SYMPTOMS ARE STILL TROUBLING YOU

  WHAT’S THE NEXT STEP?

  12.Maintaining Your General Health to Minimize Symptoms

  TIPS ON HORMONES AND MENOPAUSE, YOUR GYNECOLOGIC HEALTH, AND HIDDEN TRIGGERS OF PELVIC-FLOOR PROBLEMS

  13.Seeing the Doctor

  WHERE TO GO, WHAT TO EXPECT, HOW TO PREPARE

  14.Preparing for Pelvic Reconstructive Surgery and Optimizing Your Recovery

  CHOICES, EFFECTIVENESS, RISKS, RECUPERATION, AND WHAT TO DO WHEN THINGS DON’T FEEL FIXED

  Afterword: The Stage Is All Yours

  NAVIGATING THE POLITICS, ECONOMICS, CULTURE, AND ETHICS OF CHILDBIRTH

  Appendix A. Kegel Exercises, Biofeedback, and Other Techniques to Strengthen Your Pelvic Floor

  Appendix B. Voiding and Symptom Diary

  Appendix C. Organizations, Resources, and References

  GLOSSARY

  BIBLIOGRAPHY

  Preface

  BEYOND THE LABOR ROOM AND AFTER THE PUSH: INTRODUCING A LONG-OVERDUE CHAPTER IN WOMEN’S HEALTH CARE

  The decisions made during childbirth have consequences that can last a lifetime.

  You’ll find no mention of pelvic prolapse or urinary or fecal incontinence in prenatal classes, and little attention devoted to them in menopause guides. But ask a soccer mom or baby boome
r about leaking, bulging, pads, and diapers in private, and you’ll be likely to hear a personal story, see a surgical scar, or be asked the question “You mean that’s not normal at my age?”

  Not normal, but very common.

  Out of three million women who have vaginal deliveries each year in the U.S., between 5 and 30 percent will become incontinent of urine, a number that increases to over 60 percent by the time they reach menopause.

  Up to 65 percent will first notice their loss of bladder control during pregnancy or after childbirth.

  Roughly forty thousand of these three million individuals will eventually suffer anal incontinence—a loss of control over their bowels—although only a fraction of them will ever acknowledge the problem to a physician.

  Though it’s difficult to imagine, by age seventy, 11 percent of the general female population will undergo major surgery for pelvic prolapse or incontinence—a number roughly equal to their lifetime risk of breast cancer.

  Although sexual dysfunction is reported by up to 43 percent of women when they are asked, many others quietly accept it, viewing diminished sexual satisfaction and pleasure as an inevitable aspect of a postreproductive body.

  Finally, countless women notice that something else has changed during their postreproductive years—for some right after childbirth, for others not until decades later—around the pelvis, bladder, vagina, or bowel. Perhaps an episiotomy that never felt fully healed, pelvic pain, constipation, or an unruly bladder waking them at night. Incontinence, prolapse, urinary and sexual dysfunction—the major consequences of childbirth injury to the muscles, tissues, and nerves of the pelvic floor—have remained among the most common and costly medical disorders suffered by women, yet probably are the least discussed.

  If you’re among the many women affected by one of these problems, then you already know that the physical changes behind these astounding numbers are by no means cosmetic or trivial. They are conditions that can influence any woman’s sense of control, self-esteem, independence, and sexuality. They can lead to social withdrawal of even the most vigorous women, and physical deconditioning of otherwise robust individuals who steadily abandon their exercise routines. They can represent the difference between staying home or exercising, attending the theater, and lifting children and grandchildren without hesitation.

  We live in a world of women more physically fit and active than ever before, but perhaps you find yourself limited by the most basic concerns imaginable: control over your bladder or bowels. Perhaps you’ve noticed bulging and pressure symptoms “down there” and are wondering what exactly has gone wrong, or if it might get worse. Maybe you’ve been concerned about a change in your sexual satisfaction and about whether or not these changes are permanent, or how they might affect your relationship. If these issues sound familiar and you’re seeking explanations and advice, then take a seat and read for a while. You’ve turned the first page of a long-neglected chapter in women’s health care.

  A Guidebook for Postreproductive Problems

  This book is about improving your understanding and restoring control. You’ll gain a new perspective on the female body and understand the effects of pregnancy and childbirth on its form and function. You’ll learn what we know about preventing pelvic-floor disorders in the first place. If you’re already coping with symptoms, you’ll become familiar with countless ways to help yourself through lifestyle, exercise, diet, and healthy habits. The wide world of office therapy and surgical treatments—ranging from simple home tips to cutting-edge medical technology—will be covered in practical terms. And you’ll have a reference for your decision making, office evaluation, and treatment, whether at home or in the operating room.

  What about all of those robust middle-aged models promoting adult diapers and hygienic pads? You’ve probably come to realize that this approach is discouraging at best. It’s time to familiarize yourself with a wellspring of far more satisfying alternatives. Did you know, for instance, that finding relief may be as simple as changing your diet, starting a new exercise routine, or using simple medications you may already have in your medicine cabinet? Are you aware that office collagen injections can cure many cases of urinary incontinence as effectively as they can plump a Hollywood starlet’s lips? Or that tiny pacemakers and magnetic chairs might help you to restore control over your bladder, and that the latest operations for urinary incontinence can often be performed with local anesthesia and no hospital stay? Do you know how to maximize your chances for a successful surgery and optimize your recovery afterward? The chapters ahead will shed new light on female problems, but more importantly, they will teach you how to ameliorate, prevent, and cope with these conditions.

  Preserving Wellness, Restoring Control: A Guide for Women of All Ages

  Whether you’re contemplating pregnancy, are in the midst of your childbearing years, or are looking back on those years to realize that they marked the beginning of problems that made life a bit less carefree, this book is for you. There are many ways to treat, reverse, and sometimes even prevent these conditions, beginning right in your own home. Promoting health for the most intimate areas of your body, maintaining control over your most basic physical functions, and preserving your sense of youth and sexuality: these goals deserve a place in your health planning at any age.

  If you are an expectant mother or contemplating having a baby, did you know that pelvic exercises could lower your risk of incontinence after delivery? Are you aware of the risks and benefits of forceps delivery or episiotomy and what their proper role should be? What are the real effects of perineal massage, alternative pushing techniques, natural labor, or your choice of anesthesia? Though we have much to learn, a great deal is known about the long-term effects of childbirth on your body, including risk factors, treatment strategies, and prevention. You may be surprised to hear about all that can be done before, during, and after delivery to best maintain your gynecologic, urologic, and even sexual health—and you deserve a candid discussion. Indeed, choices made during childbirth have consequences that can last a lifetime. This book will enhance your ability to make informed decisions.

  If you’re already a mother and are considering having another child, you may be wondering if mild pelvic troubles will get worse or whether your obstetrical strategy should be different this time. Along with your family planning, these areas of personal planning should also be addressed. Now is the time to inform yourself and enhance your ability to discuss these topics with your doctor or midwife. Your daily habits and approach to future pregnancies may have major repercussions on the future physical well-being of the pelvic floor and the function of your postreproductive body.

  If, as a baby boomer, you’ve convinced yourself that the problems your mother dealt with are inevitable milestones of growing older, read on. After all, you are part of the largest cohort of women ever to reach their postreproductive years, and the first to demand, with a unified voice, more state-of-the-art solutions than adult diapers and pad liners. As a group, you have higher expectations than ever before for remaining fully active and enjoying a high quality of life. For a surprising number of individuals, that means effectively treating physical changes that had long been ignored: incontinence, prolapse, sexual dysfunction, and other problems of comfort and control that affect the female body after childbirth. In the chapters ahead, you will become familiar with all the options for prevention and treatment—at home, in the office, and in the operating room.

  Learning about what to expect while you’re expecting is important, but you should also know what to expect over the years that follow. You should equip yourself with the basic tools you’ll need to prevent problems and to cope with symptoms. Whatever your stage in life, you should be aware that normal life as a postchildbearing woman is not a daily routine of pads and liners, or a struggle with symptoms that diminish your enjoyment of life at home or work, at the gym or in the bedroom.

  New Perspectives on Women’s Health: Telescopes, Microscopes, and Mo
re

  Childbirth is the most fascinating natural convergence of science, politics, economics, and miracle. There is no other biological event so intriguing, and so charged with personal, gender, and social issues. The vision of a natural delivery, deciding on a midwife or doctor, the choice over anesthesia, the idea of home birth—so many anxious issues surrounding a medical event that can never be fully anticipated or engineered. Its potential physical repercussions, likewise, encompass a great deal more than scientific facts and figures.

  This book aims to provide a newly expanded perspective on your reproductive health by illuminating a number of often overlooked connections between obstetrical events and their gynecological repercussions, and by exploring how a wide array of nonmedical factors—including economics, health policy, even ethics—can influence your likelihood of facing these physical problems. Our journey toward understanding your postreproductive problems will lead us through worlds both big and small: from the tissue level of female pelvic anatomy and the function of your bladder and bowels to the societal level of health systems, gender politics, and your medical insurance. We’ll need both microscopic and telescopic vision to see and understand the spectrum of childbirth’s physical effects in its full context.

  For starters, aim a telescope toward certain urban communities in Brazil, Colombia, and Peru, where cesarean rates approach a staggering 85 percent. Most of us would reflexively disregard these statistics as a product of technology-obsessed physicians, poorly informed patients, or societies preoccupied with youth and aesthetics. Perhaps, in the final analysis, these assumptions will be proven true; indeed, Brazil’s minister of health described the childbirth trends in his nation as “a vicious circle of cultural phenomena and economic influences.”