The best time to start practicing prevention is during your first pregnancy. As we’ve discussed, evidence suggests that the first pregnancy and delivery has the most potential for damage and is the one during which you can probably do the most good. So think prevention right from the start, because you may never have as good an opportunity again.
If your first pregnancy is behind you, don’t be discouraged. Several pelvic-floor problems have the potential to worsen from baby to baby, and you should be aware of all you can do to minimize this risk.
Finally, remember that professional stereotypes are most often based on at least a kernel of truth but go only so far. The stereotypical doctor, for instance, is committed to the goal of preventing catastrophe, even at the expense of more monitoring and medical intervention than necessary. The quintessential midwife stands by, encouraging her own style of nonintervention while pushing hard to achieve vaginal birth, even if it entails a prolonged struggle for all involved.
Across the decades of modern childbirth, individuals on either side of this timeless rivalry have not hesitated to portray an epic struggle of us versus them, nature versus technology, for the sake of their own particular views. William Tyler Smith, president of the Obstetrical Society of London, pleaded in the late 1800s for the science of obstetrics to be distinguished from the art of midwifery—reflecting a mutual intolerance between the two camps during a time when their differences were stark. Midwives waited too willingly through long, protracted labors, which too often ended badly for Mom; and obstetricians, eager to expedite the process, reached for the forceps far too often. But these days, the differences between skilled and upstanding providers on each side are far more subtle. You’re fortunate to live in an era when most doctors and midwives have learned from each other and have learned to get along. Some of the finest obstetricians take pride in standing by, intervening with forceps, cesarean section, or episiotomy only when necessary. And a competent nurse-midwife will not hesitate to intervene or call upon her backup for intervention when the situation calls for it. Each profession has brought a valuable perspective to the modern labor room.
That being said, the differences that still exist between doctors and midwives may be of interest to you. Overall, according to a 1997 study from the University of Washington, women who choose midwives are ultimately the recipients of 12 percent fewer resources, ranging from electronic fetal monitoring to cesarean birth. Whether “fewer resources” ultimately represents an overall advantage or a disadvantage is a complex debate that lies well beyond the scope of this book. Likewise, a 1995 Public Citizen Research Group survey reported an 11.6 percent average cesarean rate among midwives, lower than the 23.3 percent national average at the time. Again, which of these represents the most accurate cesarean rate is not clear.
Whatever your outlook, be sure that whomever you choose brings experience and provides first and foremost a safe birthing environment. Look past the timeworn stereotypes, listen to the attitudes and beliefs of the provider, and consider whether your body is receiving the attention it deserves throughout the process.
THE DOULA EFFECT
Doulas are female birth assistants, experienced in childbirth, whose coaching, reassurance, and continuous support throughout labor and delivery have been shown to help some women cope with pain, push more effectively, and perhaps deliver more quickly. One 1991 study from Case Western Reserve University randomly assigned 412 woman to receive either doula assistance or no doula assistance. Was there a “doula effect”? Substantially lower rates of epidurals, forceps deliveries, and cesarean sections were seen among women with doulas; and labors were, on average, two hours shorter. A recent metaanalysis of eleven clinical trials concluded that continuous doula support—when compared with no doula support—is linked to shorter labors, decreased use of pain medication and oxytocin (for stimulating contractions), and lower odds of both forceps and cesareans. Maybe the lesson is that moral support, whether from doula, friend, relative, or partner—can have physical consequences.
PREDICTING PROBLEMS: SKIN LINES, PELVIC SHAPES, AND BEYOND
Each baby descends through the pelvis by twists and turns, during hours of stretching and compressing past the key pelvic supports. But predicting the ease or difficulty of its journey, and forecasting whether any physical problems will be left in its wake, has stumped medical science for centuries. How smoothly will your labor and delivery progress? How likely are you to experience a pelvic injury to your muscles, ligaments, fascia, or nerves? Even today, answers to these questions remain for the most part a medical mystery.
For generations, obstetricians have searched for links between outer physical traits and inner pelvic-floor vulnerability. Some of these traits are downright quirky: double-jointed fingers and stretchy skin have each, in the past, been identified as red flags signaling a higher risk for developing incontinence and/or prolapse, perhaps due to those individuals’ relatively weak connective tissues. Whether these research findings can help us to predict or prevent injuries remains unclear. In the 1940s, some obstetricians were even convinced that striae—those colored lines that appear on the abdomen as the pregnancy hormones surge—could predict the risk of pelvic injury. “When the striae are broad and coarse, laceration of the perineum is likely, and early episiotomy is indicated,” they claimed, yet “when there are no or fewer striae, there may be little risk.” Again, an interesting theory, but its reliability has never been proven.
Since those days, the search for maternal risk factors has continued. A recent study of 131 women found that a perineum shorter than three centimeters increased the risk of rectal injury from 4 to 40 percent, and a risk of forceps or vacuum delivery increased from 9 to 28 percent. A study from Great Britain indicated that when bladder ultrasound showed a high degree of mobility within the urethra and bladder before delivery, it foretold a greater risk of incontinence afterward. Abnormal spinal curvature has been associated with over three times the usual risk of pelvic prolapse, according to one recent study. Among African mothers, those shorter than 150 centimeters (just under five feet) were found to be at increased risk for disproportion between baby and pelvis, leading to failed labor. African mothers shorter than the tenth percentile had double the risk of cesarean delivery and fifteen times the average risk of needing forceps or vacuum assistance. And a report from the University of Miami of more than fifty thousand women found that even age might relate to susceptibility of the pelvic floor. During a first delivery, severe lacerations involving the anal sphincter or rectum were less likely among younger moms.
Despite these scattered insights into the relationship between each woman’s outward appearance and her risk of pelvic-floor problems, a clear and reliable picture of the woman at risk has yet to emerge.
PELVIMETRY: MEASURING YOUR PELVIC PROFILE
Few obstetricians or midwives will be likely to count your striae or check whether you’re double-jointed during a prenatal office visit. But pelvimetry is a technique that could play a role in your care. Pelvimetry measures the distance between specific bones of your pelvis during a regular pelvic examination. How much space is present within the pelvis? Where is it narrow, and where is it wide? How does the baby fit into your pelvic bones? Remember those classic pelvic shapes described in chapter 2? Obstetricians and midwives can use pelvimetry during pregnancy or labor to determine which category you fit into. High-tech variations include the use of X rays, CT scans, and MRI.
PELVIMETRY: A WORK IN PROGRESS
Forecasting pelvic-floor injuries and postreproductive problems based on pelvic shape poses more questions than answers. If you have a short anthropoid pelvis, what’s the risk of injury to the bladder or rectum? If your pelvic walls are very narrow, will a forceps delivery put you at high risk for pudendal nerve injury or a severe vaginal tear? Might a narrow pelvic arch force the fetal head away from the front of the pelvis and toward the rear, leaving you at greater risk for anal injury? Unfortunately, neither regular nor high-tech pelvime
try is a perfect predictor for the course of labor and delivery, or for identifying a pelvic shape that can accurately foretell a rough time in the labor room. But for pelvic shapes that are markedly abnormal, pelvimetry may help by warning the obstetrician that she needs to be on the lookout for trouble. Along with more accurate technology and more research, our ability to predict will hopefully improve.
Later in Pregnancy: Your Due Date Approaches
“My sister had an eight-pound, six-ounce baby and wound up with big problems. Is there anything I can do differently?”
As your due date approaches and you’re surrounded by the commotion over painting the nursery, planning the baby shower, or tying up loose ends at work, it’s easy to overlook one of the most central issues: your body. After all, it’s undergoing rapid changes, preparing in some basic biological ways for a monumental physical event. As we’ve discussed, it’s not just delivery but pregnancy itself that sets the stage for postreproductive problems. There’s no better time than pregnancy to pause and focus a bit of careful planning on yourself. Would you enter into any other major physical challenge without stretching, working out, and getting yourself in shape?
EXERCISING YOUR PELVIC FLOOR
Kegel exercises are the basic workout for the pelvic floor, which you’ll learn all about in Appendix A. Your first pregnancy is one of the best times in your life to learn pelvic-floor exercises. Not only because the need is so great—up to 70 percent of women will have some degree of urinary stress incontinence during or after pregnancy—but also because your pelvic muscles and nerves are still at their greatest potential. These muscles will be easier for you to identify before delivery than afterward. If you’re on your second, third, or fourth pregnancy, you should still take time to focus on your pelvic-floor muscles. Building their strength will benefit your postreproductive body in several ways.
Builds a healthy reserve before childbirth. The reserves you build up before delivery may make the muscles less injury-prone and will help to accelerate your healing afterward.
Provides a useful tool during labor. Locating these muscles and developing their tone before your due date will help you to focus on relaxing them during labor and delivery.
Improves muscle strength afterward. Evaluation at six weeks postpartum has shown that women performing Kegel exercises during pregnancy prevent a loss of muscle strength and tend to emerge with pelvic muscles stronger than their prepregnancy baseline. Nonexercisers usually lose strength during pregnancy and childbirth.
Reduces the odds of symptoms. The greater your pelvic-floor muscle strength, the lower your risk for developing postreproductive pelvic symptoms. One recent study showed that starting a Kegel routine before pregnancy reduced the risk of bladder, bowel, and vaginal symptoms after a first vaginal delivery from 69 percent to around 30 percent. Of four randomized trials on the preventive use of pelvic-floor routines during pregnancy, three have shown the exercises to be beneficial, including a 1998 study showing significantly less urinary incontinence for the first six months after delivery. You’ll also preserve your ability to brace the pelvic floor during moments of stress (see Appendix A).
ANOTHER LESSON FROM THE FAR EAST
In some Eastern cultures, pelvic-floor exercises are taught during young women’s transition to adulthood—a female rite of passage. Unfortunately, pelvic-floor exercises haven’t found that sort of niche in the Western world. One Australian survey showed that only 6 percent of pregnant women had their pelvic-floor muscles assessed before childbirth. As you’ve seen, learning the exercises afterward is a much steeper hill to climb.
PERINEAL MASSAGE
The hard and still will be broken.
The soft and supple will prevail.
—Tao Te Ching
Perineal massage involves gentle stretching of the perineum, that span of tissue between the vagina and rectum, using your fingers and a bit of lubrication (K-Y jelly, Astroglide, or even a few drops of olive oil). The idea is to stretch, soften, and prepare this area with the hope that it will be less likely to tear during delivery. Using a rolling motion, gently massage and squeeze the lubricated perineal body. Nothing should be inserted into the vagina itself. Women commonly start perineal massage at around thirty-four to thirty-five weeks of pregnancy and perform it for ten to fifteen minutes each day until delivery. Other women massage for the first time only after labor has begun, as a late preparation for crowning—when the newborn’s head reaches the vaginal opening and perineum.
Will perineal massage really protect your body? Two studies have shown that it may decrease the risk of perineal injury. One demonstrated that in women thirty or older, massage performed during the third trimester of pregnancy and also during labor increased the chances of an intact perineum by 12 percent. A larger study, from Canada in 1999, involved over fifteen hundred women and found that for those without a previous vaginal birth, three weeks of perineal massage increased the odds of an intact perineum by 9 percent. A follow-up study of the same group found that among those with a previous vaginal birth, perineal massage was associated with slightly less perineal pain at three months postpartum. However, a 2001 study involving more than thirteen hundred Australian women showed no benefit to women performing massage in the labor room only.
At the very least, most women who perform perineal massage during pregnancy and/or labor view it as a positive experience. Up to 80 percent of women reported in one study that they would do it during subsequent pregnancies. Give it a try—it certainly can’t hurt. One of the simplest means of prevention may literally be right at your fingertips.
EXERCISING THE REST OF YOUR BODY AND OPTIMIZING YOUR WEIGHT
Pregnancy is a great time for exercise, for many good reasons. First, a regular mild workout routine can dramatically improve your sense of well-being and physical control at a time when uncontrollable physical events seem to be occurring all around you. Second, beyond the obvious cardiovascular health benefits, epidemiological data shows that regular exercise may help to prevent gestational diabetes. Third—and most important with respect to this book’s focus—keeping close to your optimal weight throughout pregnancy may help to reduce your odds of developing postreproductive problems.
WEIGHT
Both your prepregnancy weight and weight gain during pregnancy may be linked to your risk of pelvic-floor injury. Avoiding excess pounds means less stress on the pelvic-floor muscles and nerves during pregnancy and the months of healing afterward. One recent study showed that although women of all shapes and sizes may experience urinary incontinence during pregnancy that improves postpartum, persistent leakage is more likely among those who gain a lot of weight before delivery. A 1997 study from Denmark demonstrated that being overweight prepregnancy is a potential risk factor for urinary stress incontinence and urgency after delivery. Automatic formulas for calculating your body mass index (based on height and weight) can be found on the Internet; a body mass index above thirty has been associated with a higher risk of stress incontinence after delivery.
A reasonable target for weight gain is two to four pounds during the first three months of pregnancy, and around a pound each week thereafter; this means roughly twenty-five to thirty-five pounds for a full-term pregnancy. If you’re overweight before pregnancy, significantly less weight gain (fifteen to twenty pounds) is acceptable. Weight loss, however, should never be your goal. Always check with your obstetrician or midwife about how much weight gain is ideal for you.
Diet, of course, plays an important role in this area. One rule of thumb is that most pregnant women require an extra three hundred calories beyond their usual diet to maintain proper nutrition. For a woman of average size, twenty-five hundred calories per day should suffice. If you exercise a lot, you may need more. Avoid empty-calorie junk food, and consult your doctor or prenatal guide on the intake of protein, calcium, and other nutrients.
EXERCISE
What exercise routine is best during pregnancy? Your body will feel different—changes
in coordination, posture and balance, breathing patterns, softer ligaments, and a vulnerable pelvic floor mean you should give some thought to your routine before heading to the gym.
Warm Up, Stretch Out, and Cool Down
Five to ten minutes of stretching before and after will help to prevent injury and will be more important than ever, given the excess weight your body is carrying. Try pelvic tilts while lying on the floor, feet flat and knees bent. Inhale and tilt your pelvis upward while tightening your abdomen and buttocks and avoiding any arching of the back. Hold for a count of five to ten seconds and keep breathing, then slowly lower your body to the floor. Try fifteen repetitions a day. The same exercise can also be done while standing, with your hands on your hips. Also try gentle ankle and leg stretches, since your legs will be bearing more weight than during your nonpregnancy workout.
Aerobic Exercise
Aim to do a whole-body aerobic activity for twenty to thirty minutes, two to three times each week, along with your stretch. Walking, swimming (no diving), cycling, and exercise machines should be fine, with your doctor’s permission. Alternate with resistance or strength training (use isometric techniques or light weights only), and keep your peak heart rate at moderate intensity—under 140 beats per minute, for most healthy women of reproductive age. If you’re already a runner, you should be able to continue a modified routine, but discuss a plan with your doctor. Don’t work to the point of complete exhaustion; you should be able to hold a conversation while exercising without being short of breath.
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