Ever Since I Had My Baby

by Roger Goldberg

  Finally, it’s been shown that ten months after childbirth, women who had forceps delivery experienced a significantly weaker pelvic floor and decreased anal strength compared to those who had a spontaneous vaginal birth. That should come as no surprise. The average force of forceps against the pelvic tissues has been estimated at seventy-five pounds! Imagine a seventy-five-pound person standing on all of those nerves, muscles, and tissues and it’s easy to understand how your brief sojourn inside the labor room might affect the function and control within this complex area of your body for many years afterward.

  IF YOU HAVE TO CHOOSE: FORCEPS VERSUS VACUUM

  An obstetrician’s choice of either forceps or vacuum often depends upon the amount of room in your pelvis, the baby’s position, and the degree of molding (cone head) visible. Your doctor’s experience and professional judgment, in those instances, are invaluable. But perhaps you’ve been pushing for a couple of hours and just need a little help. In that case, either device will do. Faced with the two alternatives, what’s the best choice for your body?

  The short answer is that vacuum delivery appears to do less harm to your pelvic floor. A 1999 study randomly assigned women in need of an assisted delivery to one of these two instruments, and found that anal sphincter injury was significantly more common with forceps (79 percent versus 40 percent). Moreover, anal incontinence was also more common after forceps delivery (32 percent versus 16 percent). Another study using ultrasound found that up to 80 percent of women had anal sphincter injuries after forceps delivery, versus none after a vacuum procedure. And a report by the Cochrane Group—the British-led team of research analysts—concluded that vacuum delivery places you at a significantly lower risk of perineal injury than forceps. However, a recent review of more than ninety-one thousand births in Canada showed that both forceps and vacuum deliveries increased the risk of maternal pelvic injury. Vacuum delivery doubled the risk. Trying forceps after a failed vacuum proved to be the worst scenario, raising the risk of injury by almost sixfold.

  In summary, while both methods increase the likelihood of perineal injury, vacuum devices tend to be less physically traumatic than forceps, from the maternal standpoint. Yet in a number of specific situations, vacuum-assisted delivery simply will not work as effectively as forceps—for instance, during the delivery of a fetus with thick hair or too much molding during labor. In these cases and others, forceps may remain the best choice. On this issue, your physician will need the flexibility to weigh a wide range of benefits and risks—including risks to the fetus—and to make an experienced professional decision.

  Choice of Anesthesia

  Whether or not they entered their labor suite planning or expecting to receive pain medication, a great number of women will eventually request it. The pros, cons, and controversies surrounding labor anesthesia have been widely discussed, but one aspect of the discussion is particularly relevant to us. Could your choice of anesthesia have an impact on your pelvic floor during childbirth and your function afterward?

  INTRAVENOUS AND INTRAMUSCULAR PAIN RELIEF

  Demerol, morphine, Nubain, and Fentanyl can provide partial comfort and improve your ability to relax but will not provide numbness equivalent to an epidural. Because lower-body sensation and muscle tone are generally unaffected, there is no reason to suspect that use of these painkillers will impact the course of your labor or the integrity of your pelvic floor.

  EPIDURALS

  The effect of this popular pain reliever on the overall course of labor has been a subject of debate. Some experts suggest that because epidurals help to relax the pelvic-floor muscles, they may facilitate a smoother and less traumatic delivery. Others have voiced concern that by leaving the delivering mother too numb and unaware of her labor, epidurals may increase her odds of needing assistance with forceps, vacuum, or even a cesarean delivery.

  Is there evidence to support this concern? The potential effects of epidurals on perineal injury were assessed in a 1995 study from Brigham and Women’s Hospital. Looking back at large numbers of women after delivery of their first baby, the investigators found that severe perineal lacerations occurred in 16 percent of women with epidurals, versus only 9.7 percent of those without. But further analysis showed that this difference most likely resulted from higher rates of episiotomy and forceps and vacuum delivery among women with epidurals. A more recent study, from Switzerland, evaluated eighty-two women during and after their first vaginal delivery. There were no differences in terms of bladder function, pelvic-floor strength, or sexual function when epidural and no-epidural groups were compared ten months after delivery.

  In other words, rather than avoiding the epidural per se, avoiding forceps and episiotomy whenever possible appears to be the key to preventing injury in the delivery room. Could epidurals, though, somehow increase your risk of needing a forceps or vacuum delivery? This remains a subject for debate that future research hopefully will settle.

  Selecting a Cesarean—Should You Have the Right to Choose?

  Stop for a moment, refill your coffee cup (acid neutral and decaffeinated, of course), and give a few moments’ thought to some eye-opening statistics. First, a 1996 survey of obstetricians published in The Lancet (a British medical journal), revealed something remarkable about the way doctors view the effects of labor and delivery on the female body. Over 30 percent of female obstetricians in England reported that if faced with a normal full-term pregnancy, they would select cesarean over vaginal delivery. And 80 percent of these individuals cited concern over perineal injury as the main reason behind their choice. Another survey of female gynecologists found, somewhat more modestly, that 16 percent would personally choose cesarean delivery for delivering a full-term, normal-size infant. The reason, again, was pelvic-floor injury—specifically, the desire to prevent incontinence and pelvic prolapse.

  The opinions of these female physicians are very telling, but they don’t speak for all practitioners. A survey of 135 midwives found that only 6 percent of these practitioners would choose cesarean to protect their pelvic floor. Then again, midwives provide care to women only before and during childbirth—not years later, when the majority of the injuries we’ve discussed begin to occur.

  THE GREAT DEBATE

  It’s truly a billion-dollar question, sitting right in the middle of a busy societal intersection where medicine, economics, politics, public health, and ethics all converge. Should women have the opportunity to accept the risks of cesarean—both maternal and possibly fetal, which we’ll discuss in a moment—in order to possibly reduce their risk of developing incontinence, prolapse, and pelvic-floor dysfunction later on? The concept of routinely performing one major surgery to reduce the possibility of a future one is a big conceptual pill to swallow. Moreover, the notion of a woman choosing the route of childbirth, rather than her doctor, sounds equally foreign to our ears. But doctors, nurses, and others involved with childbirth are debating these ideas in many parts of the world. Their attitudes and conclusions are interesting, if often wildly divergent. Consider, for instance, Dr. W. Benson Harer, president of the American College of Obstetrics and Gynecology arguing on national television in June, 2000 that women should be given the option to choose a cesarean section to prevent injury to the pelvic floor. From a vastly different perspective, the former director of maternal and child health at the World Health Organization—referring to the runaway cesarean rates in certain parts of South America—described that region’s trend toward elective cesareans as an “expensive and dangerous luxury” in a June 2001 Wall Street Journal article. The debate has many sides, seasoned with not only medicine but also politics, economics, and ethics.

  Let’s boil a very complex set of issues down to one simple question: if 31 percent of British female obstetricians would choose a cesarean for themselves if given the option, should you have the right to choose? The views of nonmedical women, like yourself, appear to vary depending on how much information they receive. For instance, one survey found that
women with no prior deliveries who were not informed of the link between childbirth and pelvic-floor injury would select cesarean only 5 percent of the time. Contrast this with another study, which presented young laywomen with the hypothetical scenario that vaginal delivery would carry a 15 percent risk of urinary incontinence later on. Roughly 50 percent of these women reported that they would choose the operative delivery over the incontinence. Obviously, women who are provided with accurate information tend to make different decisions.

  Within our service-oriented society, it’s unclear whether physicians should consider offering the “service” of cesarean delivery to patients who request it with the goal of protecting their pelvic floor. In a survey of Israeli physicians, 45 percent supported each woman’s right to choose cesarean delivery, and half stated that obstetricians should inform their patients of this right. The bottom line is that in a medical world where other topics, such as hormones, herbs, and cholesterol, are discussed until we’re all blue in the face, women deserve at least some open discussion of different childbirth strategies and their potential repercussions. Whatever her birthing philosophy or final decision, and whether or not she is permitted to choose cesarean, each woman should at least be provided with enough candid information to have her own educated voice in the debate.

  HOW RISKY ARE CESAREANS?

  Cesarean delivery under spinal or epidural anesthesia is safer today than at any time in the past, and that’s a blessing for women with medical or obstetrical conditions that require one. But make no mistake, a cesarean section is still an operation and still carries risk. Even if the risk of later pelvic-floor or bladder dysfunction could be decreased, at what broad cost would this narrow gain be achieved?

  For babies, temporary respiratory problems may be slightly more common when cesareans are performed before labor begins, since squeezing through the birth canal may help to expel amniotic fluid (water) from the baby’s lungs. A small risk of a surface skin injury to the newborn during the incision into the uterus is another potential problem, though the great majority leave no lasting mark.

  For Mom, cesareans entail higher amounts of blood loss, higher rates of infection and venous blood clots, temporary slowing of bowel function and anemia after delivery, and an overall longer recovery. The chance of needing a hysterectomy due to hemorrhage is increased up to ten times that of vaginal birth, though this complication is quite rare. In the long term, cesareans can cause adhesions (scarring inside the abdomen), which on rare occasion can lead to pain, bowel obstruction, or bladder injury during future operations. Because the degree of scarring may increase a bit after each successive surgery, it’s often not the first cesarean that raises concern but rather the ones that follow. One cesarean will most often be followed by future elective cesareans. Future pregnancies may be complicated by abnormal growth of the placenta into the uterine scar (placenta accreta), placental separation (placenta abruption), growth of the placenta over the cervical opening (placenta previa), and rupture of the uterine scar—all of which can cause severe bleeding and serious risks to both baby and Mom. With multiple cesareans, the risks of these disorders can dramatically increase.

  The risk of maternal death has fortunately become a rarity for any mode of delivery in the developed world—statistically less likely, in fact, than being struck by lightning. A 1998 study from the United Kingdom reported on more than a hundred and fifty thousand cesarean births performed before labor ever began, and concluded that although the risk of maternal death is extremely low for any delivery route, cesarean carried the greater risk of maternal death. In contrast, a more recent study of more than two hundred and sixty thousand women in Washington State concluded that cesareans were not directly responsible for a higher risk of death. Rather, it appeared that women who underwent cesarean were at slightly higher risk only because they entered childbirth with more complex underlying problems—in other words, medical baggage.

  Finally, cesarean delivery carries psychological disadvantages for some women. Bypassing the natural birthing process may trigger feelings of failure or guilt, or a diminished sense of womanhood. Others fear that bonding with their newborn may be compromised if their baby enters the world suddenly, through an antiseptic abdominal incision, rather than slowly, through the natural birth canal. For countless others, greeting a newborn baby feels equally gratifying and miraculous, whether it occurs in the labor room or the operating suite. What should be common to all of these individuals, whatever their birthing philosophy, is that they’re provided with all of the information necessary to make a truly informed choice.

  The bottom line? Cesarean section is major surgery, carrying inherent physical risks from maternal, fetal, and even psychological perspectives. Although these risks are substantially lower than in years past, they remain significant. The debate over cesarean by choice is a perfectly legitimate one, so long as the potential hazards of this operation are never taken lightly.

  HOW PROTECTIVE WOULD A CESAREAN REALLY BE?

  Another billion-dollar question: do we have any proof that a cesarean would help prevent the postreproductive problems we’ve discussed? After all, there’s reason to suspect that in a substantial number of cases, pregnancy itself may be enough to cause pelvic-floor injury, with the route of delivery playing only a minor role. Not enough research has been devoted to this challenging question in women’s health; nevertheless, some basic patterns have become reasonably clear.

  NERVE AND MUSCLE FUNCTION

  A cesarean delivery can protect against nerve injury and spare muscle function, compared with a vaginal birth. But not all cesareans are equal in terms of their potential benefit. One study of ninety women in their first pregnancy found that when cesareans were performed before labor began, the women were completely protected against pudendal nerve injury; in contrast, cesareans performed after labor had begun resulted in a risk of nerve injury similar to vaginal birth. Other studies have confirmed that late cesareans don’t fully eliminate the risk of injury to the pelvic nerves, or even the anal sphincter. The most protective cesareans of all—the ones that help to avoid injury to the key structures of the pelvic floor, and to prevent a number of postreproductive problems—appear to be those performed in the first pregnancy, before labor ever begins. In other words, timing is key.

  URINARY INCONTINENCE

  Though not totally eliminated, stress incontinence is far less common after cesarean, as compared with vaginal birth. One of the few studies examining this topic found that 24 percent of women were incontinent of urine three months after vaginal delivery, compared with only 5 percent after cesarean. A report from Britain tracked the symptoms of 1,169 women before and six months after their first childbirth. Impressively, cesareans performed before the onset of labor were associated with only 40 percent of the risk of stress incontinence seen after uneventful vaginal births, and lowered the frequency of accidental leakage by two thirds. A recent study of mothers of multiples found a 50 percent lower rate of urinary stress incontinence among those whose deliveries were all cesarean. A recent report from Washington State found that women undergoing cesarean reported a 60 percent decreased risk of urinary-voiding dysfunction (rather broadly defined as either urinary incontinence or difficulty emptying) during the postpartum period.

  ANAL AND RECTAL INJURIES

  Serious injuries to the anal sphincter are nearly nonexistent after elective cesareans that are performed before labor begins. But since “cesareans for all” could never be justified for this protective purpose alone, the challenge is to identify those women most at risk. For instance, it’s been felt that for women carrying babies larger than four thousand grams, the benefits of cesarean may outweigh the risks. A 2003 decision analysis from the University of Louisville recently tested this assumption, concluding that a policy of elective cesarean delivery does appear to be a medically sound strategy for preventing anal incontinence among first-time mothers with babies larger than 4500 grams. Others argue against elective cesarean for
this purpose, estimating that approximately twenty-three unnecessary cesarean deliveries would be performed to prevent a single woman from developing fecal incontinence.

  THE MOST IMPORTANT DATA: YOUR FEELINGS!

  Many women suffering prolapse or incontinence feel in retrospect that they would have strongly considered cesarean over vaginal delivery if they could have been assured of some protection against postreproductive problems. But for each of these individuals, a handful of others wouldn’t change a thing about their vaginal birth experience. Childbirth will always be viewed through the lens of not only science and medicine but also politics, diehard opinions, and ultimately, very personal choices.