VAGINAL BIRTH AFTER CESAREAN: A PENDULUM OF POLICY STILL IN SWING
Vaginal birth after cesarean section (VBAC) has been an obstetrical topic mired in controversy. Up until the past few decades, VBAC was rarely attempted, due to the concern that the previous uterine incision might rupture under the forces of labor, risking a catastrophic situation for both mother and baby. As a result, few doctors deviated from the golden rule: once a cesarean, always a cesarean. But over the years, it became clear that VBAC could succeed for the majority of women who tried it—and although uterine rupture remained a potentially catastrophic event, the chances of it happening appeared small (0.5 percent if a standard low-horizontal uterine incision was made).
So the trends began to reverse. In 1987 the National Institutes of Health delivered a statement actively promoting VBAC as a safe and desirable alternative. The American College of Obstetricians and Gynecologists followed in 1998, with guidelines making VBAC a preferred rather than optional strategy for most women with a prior cesarean. A study of twenty-nine thousand Swedish women with prior cesareans seemed to bolster that shift in policy, since having a repeat cesarean was shown to triple the risk of needing an emergency hysterectomy due to unexpected hemorrhage, as compared with VBAC. From 1989 to 1996, the rate of vaginal birth after cesarean rose by 50 percent. Insurance providers, managed-care organizations, and hospitals recognized VBAC as one of the ripest opportunities to lower the cesarean-delivery rate and rein in obstetrical costs. Patients and professionals were reeducated to expect an attempted vaginal delivery for women with a previous cesarean; not surprisingly, many women valuing the idea of natural birth met those trends with great enthusiasm. Entire books since then have been devoted to helping women achieve VBAC, and the range of situations considered suitable for attempting it has consistently widened. A recent Canadian study indicated that even women who underwent previous cesarean for a labor that failed to progress during the second stage—a group that earlier studies had identified as unlikely to succeed with VBAC—could achieve a vaginal birth up to 75 percent of the time in a modern obstetrical setting.
Yet with the latest swing of the pendulum, new concerns have been brought to the fore. Just because we can succeed with VBAC most of the time, should we? A 1996 study of more than six thousand women fueled the new debate, concluding that certain fetal complications (mainly fetal distress resulting from rupture of the uterine scar) were more common with VBAC than with a second elective cesarean. A 2001 study from The New England Journal of Medicine, the largest study to date, found that VBAC was riskier to both mother and child than a second surgical delivery in terms of uterine rupture, particularly if labor was induced with certain medications. Among the unfortunate women who had uterine rupture in this study, the rate of infant death increased tenfold. The risk of uterine rupture, though still small, has been on the rise as the practice of VBAC gained in popularity, even tripling in the state of Massachusetts between 1985 and 1995.
The ongoing push for VBAC has not been sufficiently scrutinized in one very important way: what are its effects on the overall risks for pelvic-floor injury and postreproductive problems? Not all cesareans are one and the same. Some may have been performed for reasons unrelated to the fit between mother and baby that aren’t present the next time around, such as an abnormal fetal heart rhythm or breech presentation. Other cesareans are necessitated by bodily features and limitations of pelvic shape that don’t change much from one pregnancy to the next, such as an android pelvis or a narrow pubic arch.
Could a cesarean for stalled labor during second stage sometimes indicate a pelvic shape that makes a smooth vaginal delivery no more likely with the next try? One Canadian study involving 214 such patients recently reported that VBAC can be achieved 75.2 percent of the time. But the question is, at what cost? In this study, the rate of forceps or vacuum delivery was fairly high, at 15 percent, and no mention was made of how long it took to achieve the vaginal birth or how these factors might affect pelvic-floor function. Many other questions remain unexplored. For instance, should an incontinent woman whose last labor arrested after many hours be automatically encouraged to try for vaginal birth again? A recent study from the University of North Carolina reported higher rates of stress incontinence, and worse quality-of-life scores, among women delivering by VBAC, compared to those having another cesarean. Sexual dysfunction was also more common after VBAC. More research is needed to clarify the relationship among VBAC, incontinence and prolapse, and other aspects of pelvic-floor function.
In 1999 the American College of Obstetricians and Gynecologists issued a statement rejecting an overall mandate for VBAC and stressing the importance of an individualized decision for each woman in each pregnancy. The National Center for Health Statistics has reported a small decline in the VBAC rate over the past few years—though whether this trend is significant is yet unknown. Wherever the pendulum may be when your due date arrives, individualize your decision making. Ask about the reasons for your last cesarean, the possible role of your pelvic shape, and any other reasons why your odds for a successful delivery might be different this time around.
CESAREANS A CURE-ALL? FORGET IT!
Incontinence, prolapse, and other pelvic-floor disorders are, as you’ve seen, very common among women who have had a vaginal childbirth. But are you aware that up to 5 percent of women who have never given birth by any route report incontinence? Or that a loss of bladder control may arise in up to 9 percent of women who have had a previous cesarean section alone? A number of experts have challenged the notion that labor and vaginal delivery are the most critical factors in the development of incontinence, and they propose that pregnancy and childbirth by either route may be enough to tip the tenuous balance of a healthy pelvic floor. Indeed, although birth mode is an important factor, certain women may be destined to develop incontinence regardless of their obstetrical road. As a result, cesareans are by no means a risk-free, clear-cut panacea for solving the problem of pelvic-floor injury. Determining the “best” obstetrical strategies will require ongoing debate and further research.
After Delivery
HOW TO MOST FULLY HEAL AND PREVENT PELVIC-FLOOR PROBLEMS DURING THE POSTPARTUM PERIOD AND BEYOND
I used to be able to do thirty-two changements (jumps) in ballet class; now, after the birth of my twins, I can’t sneeze or cough without wetting my panties.
—Letter from Australia
After you strain a back muscle, common sense tells you to avoid heavy lifting for at least a week or two. After you finish the Boston Marathon, the days that follow should be filled with ice packs, rest, and massage. But despite the remarkable level of stress endured by your lower body during labor and delivery—leaving behind stitches and bruises, swollen muscles and battered nerves—most women devote little attention to recuperation. You can do better. Starting right after childbirth, be sure to consider some basic ways to care for yourself and help your pelvic floor get back to normal.
Starting With Postpartum Rehab
HEALING FOR YOUR PERINEUM
If you’ve had a laceration or an episiotomy, apply ice packs to the perineum for the first forty-eight hours to reduce swelling. Try ten minutes at a time followed by a twenty-minute rest. When you’re lying in bed or on the couch, elevate your legs.
Hygiene is essential to proper healing. Keep the perineum clean and generally dry, with frequent pad changes to avoid infection and early breakdown of your stitches, which take several weeks to dissolve. Avoid the temptation to use lotions or ointments, and keep hemorrhoid creams away from the stitches. Don’t directly scrub the healing area, and when drying your bottom, pat the area rather than wiping. Before you leave the hospital, the doctor or nurse will usually specify whether you should be cleaning with showers, sitz baths, or tub baths. Once again, simple is best. Lotions, soaps, and bath oils are unnecessary and may irritate your vulvar skin.
HEALING FOR THE PELVIC FLOOR
As you’ve already learned, the real actio
n during childbirth takes place out of our view, closer to the bottom of the pelvic-floor “iceberg”—the levator muscles, fascia supports, and nerve supply. Well, your pelvic floor just finished the Boston Marathon, and it’s time to give it the TLC it deserves.
RESUME KEGEL EXERCISES
Restoring the tone of your pelvic-floor muscles after each delivery will reacquaint you with the levator muscles and strengthen them at a time that they’re most prone to neglect. One study discovered the rather discouraging fact that almost 79 percent of women were unable to properly contract their pelvic-floor muscles a year after childbirth.
With a bit of exercise during the postpartum months, the odds of your restoring this function before it’s forever lost will increase dramatically. Strong levator muscles will help prevent vaginal laxity and give you the best resistance to postreproductive symptoms before they ever arise. Getting back to strong pelvic exercises will also restore your ability to brace the pelvic muscles and prevent urine leakage during sudden moments of stress or strain, a reflex that can be lost as the perineum and vagina heal.
Pelvic-floor education after vaginal delivery—in other words, having the doctor or nurse show you how to contract the correct muscles and get you started on a pelvic-floor exercise routine—has been shown to significantly reduce symptoms of stress urinary incontinence. One Swiss study demonstrated that this type of program, begun two months postpartum, reduced incontinence symptoms from 19 to 2 percent of women. A study from New Zealand indicated that an intensive pelvic-exercise program involving personal instruction and multiple daily workouts may be more effective than simple instruction. After one year, the intensive exercisers experienced less urinary incontinence, fecal incontinence, and lower levels of anxiety and depression. However, this study, like most others, showed that incontinence symptoms will improve only as long as you continue the exercise routine.
GOOD BOWEL HABITS
The way you empty is important after delivery. Avoid constipation to minimize the amount of straining against the levator muscles, pelvic nerves, and any perineal stitches. Some women may be instructed to support the perineum from the front side, with a flattened hand, during bowel movements. If you do so, just beware of soiling this area. Using plenty of dietary fiber and stool softeners, along with occasional laxatives or suppositories as needed, will hopefully make straining unnecessary and keep your perineal stitches safe. See chapter 10 for more tips on avoiding constipation.
DON’t DENY IT—YOU’RE HEALING!
We live in a society that places great value on a back-in-the-saddle spirit. Although that’s a positive trend in many ways, the reality after childbirth is a bit more complex. It’s wise to step back, consider the amount of healing taking place in your body, and do what you can to optimize your chances for full healing of your pelvic floor.
Work and Exercise Sensibly
After surgery in the pelvic area, women are usually instructed in great detail about what to do and what not to do to promote the strongest healing. Yet after delivering a newborn baby through the pelvis, you rarely hear about the rights and wrongs of physical activity in the same way. Although childbirth is a natural event if ever there was one, your physical recuperation is not unlike recovery after pelvic surgery—especially if you’ve had a long labor, a large laceration, or an episiotomy. In these cases, you’re swollen and sore, and have stitches temporarily holding together parts of your lower body that you’d like to function as normally as possible for many years ahead. Leaping into a full and strenuous routine may stress these areas before they have a chance to properly heal.
Avoid Lifting
For new mothers, this may be the most practical and realistic single guideline: don’t lift anything (or anyone) heavier than your baby. Don’t make all of the countless new physical tasks—such as carrying the crib upstairs, baby-proofing the furniture, and hauling groceries—your sole responsibility during those first few weeks. That’s what a partner, friends, and family are for.
Minimize Physical Stress
Position your baby’s changing table and bathtub at waist level. Brace your pelvic floor if you happen to suddenly cough, sneeze, laugh, or lift (see Appendix A).
Exercise Right
The average woman gains twenty-five to thirty pounds during pregnancy; that weight (especially the last five to ten pounds) probably won’t be shed immediately afterward. With a reasonable routine, you can bounce back while allowing these vulnerable areas of your body to properly heal.
After two weeks. This is a great time to resume a walking routine: for example, thirty minutes each day with your baby. Your doctor may also approve pelvic tilts (see chapter 4) and mild abdominal exercises (like partial sit-ups) during this time. Twenty-minute light-duty workout sessions, three times a week, are a great start.
If you had no exercise routine before or during pregnancy, start more slowly. Don’t be hard on yourself or do too much too soon at this time, when your energies are needed for so much else. Also, if normal postpartum bleeding (lochia) becomes heavier, lighten up your exercise routine for a few more weeks.
After six weeks. Check with your doctor or midwife about returning to more vigorous aerobic and muscle-strengthening routines, swimming, and bike riding, if you feel ready. Balance abdominal exercises (sit-ups and crunches) with lower-back strengthening. If you notice a wide space between your stomach muscles, have your doctor check it out at the next routine visit (separation of the abdominal muscles is fairly common).
Fast-paced walking, weight training with light dumbbells, push-ups, postpartum yoga, and other resistance exercises are usually allowed. Exercise classes taught by postpartum specialists are increasingly popular. They focus on low-impact routines with nonstressful stretching and toning. At home, try an exercise video specifically geared to postpregnancy mothers. These group workouts can improve your technique and help make your transition back into shape feel less monotonous.
Listen to your body. Just because the obstetrical textbook says the postpartum period lasts for six weeks does not mean that your healing process abruptly ends. In reality, it may take several months or longer for your energy level and muscle tone to return to their former state.
If problems persist, ask the urogynecologist. If pelvic-floor symptoms become an issue, a number of high-tech treatments can be used even during the postpartum period. Generally speaking, urogynecologists will wait at least six to twelve weeks before recommending most of the therapies you’ll read about in the chapters ahead. But it never hurts to ask.
Effects of Breast-feeding on Pelvic-Floor Symptoms
You probably anticipated the cracked skin, soreness, and engorgement that accompany nursing. But you might be surprised to learn that breast-feeding can also cause bladder, pelvic, or sexual symptoms. Lactation triggers a hormonal chain of events that leads the ovaries into a state of hibernation. That’s why normal menstrual periods cease and the timing of ovulation becomes unpredictable. Think of it as nature’s own family-planning method, preventing Mom from getting pregnant while she’s still caring for a very needy little newborn.
Unfortunately, this drop in estrogen may also cause a few less useful changes in some key pelvic areas. The vaginal skin, when lacking estrogen, becomes thinner, less lubricated, and often a bit irritated, making intercourse uncomfortable or even painful. Likewise, the urethra may become more weak, thin, and floppy. As a result, urinary stress incontinence and urge incontinence may both become more severe while you’re nursing.
If you’re breast-feeding and notice one such change, start a basic Kegel routine on your own, and use a water-soluble lubricant during intercourse—then give it some time. Symptoms that are truly estrogen-related will improve after you’ve stopped breast-feeding, as the normal function of your ovaries resumes. If your symptoms are mild, a full medical evaluation isn’t necessary until a few months after you’ve finished breast-feeding. If changes down below remain a nuisance at that point, then it’s time to see the doctor.
After a Rough Delivery: Managing Your Next Pregnancy
If a previous childbirth left you with postreproductive symptoms, approaching your next pregnancy and delivery can trigger a great deal of uncertainty and even fear. How should you approach the process this time to avoid making your problem worse? Should your next pregnancy be considered high-risk? Should you be thinking in terms of bed rest, extra time off work, or a planned cesarean birth?
FOR PERINEAL INJURIES
Although perineal injuries are most common during a first vaginal birth, as the tissues stretch out for the first time, repeat injuries are a possibility. One study, conducted at the University of Iowa in 1999, analyzed the first and second deliveries of more than four thousand women and discovered that those with a history of severe perineal laceration during their first delivery were 2.3 times more likely to suffer a repeat injury in their next delivery. Women at highest risk were those who underwent forceps, vacuum, or a repeat episiotomy in their second delivery—around one in five suffered a second severe perineal injury. Perineal massage during pregnancy and labor, attention to fetal size and position, and avoiding whenever possible the obstetrical interventions we know to be potentially traumatic, appear to be the most effective strategies.
Ever Since I Had My Baby Page 12