Second, hormones can have a major effect on the way your bladder behaves during pregnancy and beyond. Progesterone is a hormone of pregnancy that acts like a muscle relaxant in various locations all over your body. That’s why so many women become constipated even early in pregnancy, as high progesterone levels slow down the bowel muscles. On the plus side, it’s one reason why the uterus (another smooth-muscle organ) is able to relax and stretch from the size of a pear to the size of a watermelon over the course of nine months. Because smooth muscle also happens to be a major ingredient of the bladder, urethra, and vaginal wall, high levels of progesterone during pregnancy can cause the supports of these areas to relax and stretch along with the uterus. Sometimes this relaxation is enough to tip your tenuous balance of continence, allowing leakage to occur when you cough, sneeze, or bend over to lift a can of pink or powder-blue paint while decorating the baby’s room.
So even before delivery, several pelvic-floor changes may have already occurred—enough, in many cases, to cause stress incontinence. One survey of more than fifteen hundred women experiencing stress incontinence after childbearing found that nearly 63 percent said their incontinence began during pregnancy. Other data indicates that up to 80 percent of such women will recall that their leakage began before delivery. These physical changes help to explain why even women delivering by cesarean at full term may be left with stress incontinence up to 9 percent of the time. Later on, you’ll learn a handful of tips to help minimize the effects of pelvic-floor injury during pregnancy—just as important to your prenatal routine as vitamins, hospital tours, and Lamaze.
Your Bladder During Labor and Delivery
There’s a great deal of scientific interest these days in the effects of labor and delivery on your pelvic area, including your bladder—and for good reason. A fetus compressing against your pelvis, then stretching its way through and past almost all of your pelvic muscles, nerves, ligaments, and supports can cause a number of physical problems, with stress incontinence at the top of the list. Strong as the odds for pelvic injury during vaginal delivery may be, you’d be surprised how rarely the risk of pelvic damage is factored into obstetrical decision making, and how infrequently it’s discussed with the person it actually involves: you. It’s time to become your own expert on your body during childbirth.
WILL INCONTINENCE GET WORSE IF I HAVE ANOTHER BABY?
Several studies have suggested that your first pregnancy and delivery will have a greater impact on your risk of urinary incontinence than any that follow—as if the first baby clears the way for later siblings, slowly dilating and stretching the pelvic tissues. Based on these results, even if you started to leak after your first delivery, it probably wouldn’t make sense to request a cesarean for later ones in hopes of preventing the problem from worsening. But some researchers have concluded differently. One study of more than seven thousand Irish women indicated that the risk of incontinence does indeed seem to increase with each delivery; other investigators have estimated this additional risk to be as high as 10 percent per vaginal birth. Until more conclusive research is done, we don’t know the safest and most reasonable way to prevent incremental injury from one childbirth to the next.
Big Babies and Multiple Pregnancy: Effects on Your Body
MACROSOMIA: PHYSICAL EFFECTS OF A BIG BABY
It’s been long recognized that very large fetuses (called macrosomia) face their own increased risks in the labor room, including birth trauma, shoulder dystocia (when the baby’s shoulders become stuck after delivery of the head), and even low fetal Apgar scores, used for rating each newborn’s level of alertness and activity. But delivering a very large baby can also present risks to your body. Macrosomia is associated with a higher occurrence of spontaneous perineal injury and episiotomies, nearly two and a half times the usual risk of rectal injury during childbirth, and a higher risk of pudendal nerve injury after childbirth. A Danish study of eight thousand women showed that delivery of a newborn weighing over 8.8 pounds resulted in twice the usual risk of urinary incontinence later on, and a slightly higher chance of later surgery to correct the problem. A study from Boston showed macrosomia to be associated with a 60 percent increase in the risk of episiotomy. Another study discovered that a larger newborn head circumference is an independent risk factor for perineal injury during childbirth, raising hope that in the future, more accurate ultrasound measurements of a baby’s size might allow us to predict each woman’s risk for perineal injuries. More studies are needed, however, to fully understand the postreproductive experience of mothers delivering large newborns.
TOUGH ON THE BODY, ALL OVER THE WORLD
For women carrying a large baby, looking ahead to vaginal delivery can be a nerve-wracking process. What’s the right birthing plan for both baby and you? Following a handful of tips for pregnancy and labor—such as pelvic-floor exercises and perineal massage—might help. In Part 2, you’ll learn the ways to begin.
TWINS, TRIPLETS, AND HIGHER-ORDER PREGNANCIES: WHAT ARE THE PHYSICAL EFFECTS?
Multiple pregnancy and delivery are major features of today’s obstetrical landscape, due in large part to assisted reproductive techniques used for the treatment of infertility, which often result in multiple births. The number of twin deliveries has doubled over the last ten years alone. The first study of postreproductive pelvic-floor problems among mothers of multiples recently found that among 733 mothers of multiples—their average age at the time of the study only thirty-seven—rates of pelvic-floor symptoms appear to be remarkably high.
Urinary stress incontinence. Forty-five percent of these women reported accidental leakage of urine with coughing, sneezing, lifting, or straining. Remarkably, women who delivered by cesarean had a 50 percent reduction in their risk of urinary stress incontinence.
Overactive bladder symptoms. Urge incontinence was reported by 27 percent of the group.
Anal incontinence. An inability to hold back gas in public was reported by 25 percent, some degree of fecal incontinence (loss of stool) by 10 percent, and fecal soiling by 10 percent.
Other pelvic-floor symptoms. A number of other symptoms relating to the pelvic floor were also present, including painful intercourse (20 percent) and vaginal bulging or pressure (21 percent).
Quality of life. The presence of pelvic-floor symptoms was strongly associated with diminished quality of life among these women.
These high rates of pelvic-floor symptoms among women with previous multiple childbirths need to be better understood. Is it multiple pregnancy and birth placing these women at risk, or simply their greater number of children? What aspect of multiple gestation is most high-risk when it comes to Mom’s body—carrying the weight of the pregnancy or childbirth itself? Are mothers of multiples at this level of risk simply because they’re more likely to undergo certain obstetrical procedures? Is there a best way to deliver twins, triplets, or higher? Finding better ways to prevent these postreproductive problems will benefit an ever-increasing number of women. After all, raising multiples is quite enough for these supermoms to worry about, without the pelvic-floor problems to contend with.
TURNING CHANCES INTO CHOICES: NEW PERSPECTIVES ON LABOR AND DELIVERY
Many aspects of childbirth can impact your postreproductive health. Despite the tendency to feel that your role is merely to react by reflex and accept the inevitabilities of the birthing process as they unfold, many events and outcomes are not inevitable. A number of decisions are being made, and if you’re not helping to make them, they’re being made for you. If you’re concerned with avoiding the postreproductive problems you might have seen your mother deal with, what are the right questions to ask?
When it comes to pushing, how long is too long?
Is resting rather than pushing (passive laboring) less or more of a strain on your body?
What’s the best position for your body—lying faceup or facedown, sitting, or squatting?
Can perineal massage during labor reduce your risk of second-stage tr
auma?
What risks are posed by forceps or vacuum delivery?
How about big babies or even twins?
There is a great deal not yet understood about the physical effects of pregnancy, childbirth, and their various stages. Familiarizing yourself with a handful of preventive tips, based on what is known today, might help you to prevent problems later on. In the next chapter, you’ll learn how to start turning chance into choice.
“But I Never Had a Baby!”
Pelvic-floor problems, including incontinence and prolapse, can occur even if you’ve never had a baby. Any urogynecologist can attest to this reality and recall plenty of patients with a loss of bladder control or prolapse bulging, despite never having given birth. One recent survey of nuns, interestingly, showed that up to 47 percent of them reported some degree of incontinence, with 29 percent reporting stress incontinence at an average age of sixty-eight. And in the Women’s Health Initiative—a large study of hormone use in postmenopausal women (see chapter 12)—although previous childbirth was strongly associated with increased rates of pelvic prolapse later on, 19 percent of women with no previous delivery also had prolapse.
How could this be?
Weakening of the pelvic floor can, in some cases, result from chronic physical straining unrelated to pregnancy and childbirth: in the form of routine physical exertion and exercise, a long-standing cough, or chronic constipation. Even the wear and tear of normal daily activities can be enough to cause symptomatic weakening of the pelvic supports.
As the strength of pelvic tissues decreases after menopause, due to a decline in estrogen supply, the effects are more likely to become apparent in the form of pelvic-floor symptoms.
Other women may be predisposed to a loss of pelvic support due to an innate weakness of their connective tissues—in other words, one that was present at birth. Over time, this generalized weakness may lead to problems in the pelvic area. Connective-tissue disorders run in families but are fortunately very rare.
As you learn about these postreproductive problems, remember that although they often stem from pregnancy and childbirth, this is not always the case.
From Problems and Evolution to Cures and Solutions
For humans, as with all other species, reproduction always has and will forever be our biological purpose in life. But along the evolutionary road, childbirth became more and more of a stress test for each mother’s body—painful and often life-threatening in the short term, sometimes debilitating in the long run. Modern medicine met the challenge of the short-term problems during the twentieth century: today you can take for granted that childbirth is rarely life-threatening, and its pain can be quite easily managed. But only in the past few years have the long-term physical repercussions to your body been raised for discussion. Preventing incontinence, prolapse, sexual and other pelvic dysfunction remains a challenge for the twenty-first century to confront.
Let’s start today.
PART 2
PREVENTIVE OBSTETRICS
A NEW OUTLOOK ON PREGNANCY AND CHILDBIRTH TO PROTECT THE PELVIC FLOOR AND AVOID PROBLEMS BEFORE THEY ARISE
Preparing for Your Due Date
WHAT YOU CAN DO DURING PREGNANCY TO MINIMIZE PELVIC STRAIN
Forethought spares afterthought.
—Amelia E. Barr
When it comes to the future, there are three kinds of people: those who let it happen, those who make it happen, and those who wonder what happened.
—John M. Richardson, Jr.
We all hope to chart a more healthful course through middle age than did generations past. We want to wrinkle less, exercise more, stay hipper longer, and somehow preserve our full physical functioning in ways that our parents and grandparents weren’t always able to do. Despite the reality that many age-related transitions still remain inevitable, there is a great deal we are able to prevent in this modern age of tummy tucks, lid lifts, estrogen replacement, and Viagra. Prevention has evolved from the realm of late-night-TV public-service announcements to a core crusade in mainstream society and medical practice. Dermatologists these days stress the importance of avoiding sun exposure; after all, avoiding sunburns will easily outperform the latest antiwrinkle cream or even Botox. Primary-care doctors watch your blood pressure and preach smoking cessation, since preventing hypertension will leave you healthier than treating hypertensive strokes after they’ve occurred; and quitting smoking is far more successful than cutting out a cancerous tumor from the lung.
Seat belts, sunscreen, blood-pressure monitoring, and the multi-billion-dollar industry of vitamins and herbal remedies all reflect our expectation for an increasingly long and full postreproductive life, and our willingness to plan ahead and ensure it. Today’s medical mind-set goes beyond reversing disease processes that are already in motion. It strives to keep us out of harm’s way in the first place.
Women’s health continues to undergo its own major transformation toward prevention, and as a result, today’s forty-and-up women are healthier overall than their mothers were at the same age. Deaths from heart disease have declined by more than 50 percent since the 1970s, in part because these women are more likely to exercise and less likely to smoke and drink. As menopause approaches, women are inundated with information and recommendations centering on hormone-replacement therapy and its substitutes; and though the absolute right hormonal strategy remains unknown, at least there’s a sophisticated debate taking place.
At the time of childbirth, it’s easy to take for granted the many forms of obstetrical prevention that steer a fetus from harm. Early ultrasounds can detect physical abnormalities, amniocentesis can raise a red flag for genetic problems, and a daily folic-acid tablet from the start of pregnancy can prevent birth defects. But what’s happening from the maternal standpoint?
Numerous conditions that devastated the lives of countless women only a few generations ago are now fully preventable, and maternal and fetal death are, thankfully, a rarity. Consider the obstetrical fistula—an abnormal connection or hole that forms between either the bladder and vagina or the bowel and vagina, leading to constant urinary or anal incontinence. This postreproductive disorder once left substantial numbers of women socially isolated for the remainder of their lives after vaginal delivery. By learning that fistulas were a direct consequence of prolonged and obstructed labor, we learned prevention, and today the problem is virtually nonexistent in the developed world. But what about prevention of the other physical risks of childbirth today, and the life-changing conditions that can sometimes follow years or several decades later?
Sunscreen for the Pelvis
A popular pregnancy guide compares the loss of pelvic function after vaginal childbirth to getting a sunburn while on vacation in the Hawaiian tropics. The book’s gist: just as you wouldn’t skip the opportunity for a spectacular vacation because you feared a sunburn, you should accept the physical changes that follow childbirth as part of an unforgettable delivery. In one respect, the “sunburn in Hawaii” analogy was right on target: given the information most women are provided with today, they will gladly accept the entire package of childbirth and take their chances with the “sunburn” of pelvic injury. But the comparison fails to consider one major item that you’d find packed in any suitcase headed for the tropics: sunscreen. Whether boarding a flight to Hawaii or looking ahead to a first pregnancy, every woman deserves the best available prevention, if not a full shield from the strongest rays, then at least a partial block. After all, changes to the pelvic floor are a natural consequence of labor, like skin cancer is a natural consequence of sun exposure. Both are real, both can greatly affect quality of life, and both, in many cases, are preventable.
Unfortunately, obstetricians haven’t discovered an ideal sunscreen for the pelvis. Thus far, many more dollars have been devoted to diapers and pads than to prevention. But this will change—not through luck but through science. At this moment, the National Institutes of Health is devoting millions to the study of postreproductive pelvic-fl
oor disorders, and women in the future will undoubtedly reap the fruits of these investments. In the same way that few dermatologists would neglect to mention the dangers of sun exposure today, it will be routine for tomorrow’s obstetrician to outline each woman’s best strategy for protecting her pelvic floor during pregnancy and childbirth.
How can you practice preventive obstetrics in the meantime? Some basic tips may help, before, during, and after pregnancy. For a generation of women increasingly determined to prevent disease, and to maintain vigor rather than quietly accept the physical marks of aging, the notion of preventive obstetrical care is long overdue.
The Early Stages of Pregnancy
SELECTING THE RIGHT PROVIDER FOR YOU: DOCTOR OR MIDWIFE?
Obstetrics is partly art and partly science and can be practiced in many different ways. When you choose an obstetrician or midwife, discuss his or her philosophy regarding episiotomy, pushing styles, forceps, and cesarean. If you’re already dealing with postreproductive symptoms from a prior pregnancy, discuss what might be the best strategy to prevent them from getting worse. The beginning of labor is not a good time to discover that your provider has a 90 percent episiotomy rate or recommends the use of forceps for most normal deliveries. It’ll be difficult, not to mention untimely, to voice your concern between the contractions!
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