Ever Since I Had My Baby

by Roger Goldberg

  FOR PROLAPSE

  Mild prolapse—in other words, loss of uterine or vaginal supports to some degree—is an absolutely normal occurrence for most postreproductive women. But for women who already have more advanced pelvic prolapse causing problems, whether it’s uterine prolapse, a cystocele, or a rectocele, the best strategy for future pregnancies remains a medical question mark. On one hand, studies have shown that pudendal nerve injury can accumulate with later deliveries. On the other hand, the majority of damage has already been done in most cases, and it’s unclear which obstetrical interventions, if any, will counteract its progression. There is, at present, no evidence supporting an elective cesarean the next time around. Focusing on symptom relief and following a few simple tips is probably best.

  Understand that you absolutely can carry another pregnancy. Severe prolapse should be evaluated in order to determine whether any fertility or obstetrical issues need to be addressed. But prolapse itself should virtually never cause an inability to have another baby.

  To relieve vaginal bulging and prolapse discomfort during your next pregnancy, certain pessaries—for instance, a Smith-Hodge type—can be worn (see chapter 9).

  Limit your activity, especially until later in pregnancy. By eighteen to twenty weeks’ gestation, you should feel less pressure as the enlarging uterus rises out of the pelvis and into the abdomen, usually staying up for the remainder of pregnancy. Prolapse symptoms usually improve after this transition.

  Strict bed rest may be recommended for very advanced cases, such as a prolapse bulge visible outside the vaginal opening. Absolutely avoid heavy lifting or straining.

  If your symptoms remain truly debilitating after delivery but you’re still planning future pregnancies, then a pessary device (chapter 9) might become an appropriate option to discuss with your doctor. Having prolapse does not affect your ability to have another baby in the future.

  FOR URINARY INCONTINENCE

  As previously mentioned, one study looking at first pregnancies suggested that cesarean delivery could reduce the risk of incontinence from 25 percent to only 5. Another study showed that among mothers of twins or triplets, avoiding vaginal delivery reduced the risk of urinary stress incontinence from 60 percent to 39. But it’s unclear whether postreproductive women who already have stress incontinence can prevent its progression by requesting a cesarean for the next birth.

  FOR ANAL SYMPTOMS

  Let’s assume that an episiotomy or spontaneous perineal tear caused an injury to your anal sphincter. Will you be likely to experience the same injury during another vaginal birth, increasing your odds for anal incontinence or other pelvic-floor symptoms down the road? It has indeed been confirmed using ultrasound that a good number of hidden anal sphincter injuries occur during second deliveries, some of which may lead to anal-incontinence symptoms. As already mentioned, other studies have indicated that function of the pudendal nerve may diminish. At least to some degree, postobstetrical injury to this area of the body can accumulate from birth to birth. Your first trip to the labor room may be the most important, but a second or third delivery can cause new symptoms to arise, old ones to recur, or existing ones to worsen.

  One 1999 study from Ireland published in The Lancet addressed this issue, tracking a group of women with some fecal incontinence after their first vaginal birth. For those who still had the problem at the time of their next pregnancy, almost all noticed that it became more severe afterward. For those women whose fecal incontinence had resolved by their second pregnancy, the second birth led to recurrence 40 percent of the time. The risk of having a cesarean was not studied, so it’s uncertain how protective it would have been. On a slightly more hopeful note, another study estimated that only around 24 percent of women with anal incontinence after childbirth will find it aggravated after a subsequent delivery.

  OPINIONS, OPINIONS

  Some experts have suggested that every woman with postpartum anal incontinence should be offered cesarean delivery. After all, loss of bowel control is arguably the most distressing of all postreproductive pelvic-floor problems, and if we can help prevent its progression, then why not do so? According to physician surveys, the opinions you’ll find on these subjects vary widely, depending on where you seek your advice. Surveys have revealed, for instance, that up to 71 percent of colorectal surgeons would advise women with previous anal injuries to deliver by cesarean, whereas only 22 percent of obstetricians would make the same recommendation. What about planning an episiotomy to protect a previously repaired anal sphincter? Only 1 percent of colorectal surgeons think it’s a good idea, compared with 30 percent of obstetricians. Of course, there is a myriad of differences existing between these specialists, shaping their respective attitudes and opinions, and it’s difficult to know whose advice is better. Hopefully, tomorrow’s research will help doctors and their patients to reach a better scientific consensus on these and other questions of preventive obstetrics. In the meantime, find a provider who takes the time to discuss your situation, present the alternatives, and help shape a plan that feels most comfortable and rational to you.

  Preventive Obstetrics of the Future: In Search of Red Flags

  Each woman’s body is different in shape, strength, and resiliency, and each new pregnancy and birth involves a completely unique fetal size, shape, and position. That’s why we’ve put men on the moon but still are challenged by the task of predicting the precise physical impact of pregnancy, labor, and delivery on individual women. On the wonderful journey of childbirth—just like on that Hawaiian vacation—it’s quite possible to still get burned, despite our best efforts.

  You’ve learned, however, that there are prevention strategies that you can utilize during your reproductive years—perhaps not one simple cure-all like sunscreen, but a combination of diet, exercise, communication, and planning. A mind-set of prevention before, during, and after childbirth will make you more secure and more empowered, whether you’re trying to prevent an initial injury or deal with symptoms.

  TONE UP YOUR PELVIC FLOOR BEFORE, DURING, AND AFTER CHILDBIRTH

  A regular pelvic-floor workout routine can prevent symptoms at each of these stages. In Appendix A, you’ll learn step by step how to start your Kegel exercise program.

  TRY PERINEAL MASSAGE

  Start during pregnancy. It’s right at your fingertips, costs nothing, and just might reduce your risk of perineal injury during childbirth.

  AVOID EPISIOTOMIES

  Over 50 percent of women in the United States have an episiotomy along with their first delivery, and that’s unfortunate. As we discussed in chapter 3, there’s a mountain of evidence indicating that this procedure is best to avoid whenever possible: for preserving pelvic-floor muscle strength, to prevent severe lacerations in the rectum, and to safeguard sexual function.

  The American College of Obstetricians and Gynecologists formally stated in March 2000 that routine episiotomy should not be considered a part of current obstetrical practice. However, selective episiotomy remains an invaluable obstetrical tool, and in many cases, it represents the best care.

  UNDERSTAND OTHER OBSTETRICAL FACTORS

  We’ve explored the links between pelvic-floor function and forceps delivery, prolonged labor, macrosomia (very large fetal size), pelvic shape, and various styles for labor and delivery. As you plan for childbirth and its accompanying decisions, keep these factors in mind.

  OPTIMIZE YOUR POSTPARTUM HEALING

  Promoting an optimal recovery for the pelvic floor after childbirth has been a sorely neglected aspect of women’s health care, but you can do better. If you’re still having problems after utilizing the basic postpartum strategies discussed earlier in this chapter, then it’s time to see the doctor.

  COMMUNICATE

  Your discussions surrounding forceps, laboring and pushing styles, perineal massage, episiotomies, cesareans, and other birthing practices do make a difference. Speak up, discuss the issues with your doctor or midwife, and make your feelings
clear. Then—most importantly—understand that your provider may still need to rely on an unexpected strategy at the time of delivery. Although an intervention might not have been part of your best-laid childbirth plans, it will have been done to assure the safest birth for you and the baby.

  Predicting and preventing pelvic-floor problems will, in the future, represent an increasingly principal task for the obstetrician and midwife. Perhaps through advances in prenatal pelvimetry and ultrasound, or through techniques that are yet to be discovered, the physical effects of childbirth and the likelihood of a postreproductive problem will be more accurately forecasted. With these advances, physicians and midwives will be better able to recommend vaginal delivery to some women and cesarean birth to others, and perhaps more effectively balance the pros and cons of forceps, episiotomy, and other obstetrical procedures. As our understanding continues to improve, the obstetrical red flags alerting mothers and their doctors to potential postobstetrical problems will become more comprehensible and reliable.

  “I’m Way Past Prevention!”: Moving Ahead and Finding Relief

  In just a few short chapters, you’ve learned what’s happened down there, and you have a good idea of how it all happened. You’ve bridged the gap between Ob and Gyn by understanding how physical changes that often occur during pregnancy and childbirth may connect with postreproductive symptoms. You’ve considered strategies for before, during, and after childbirth that might help prevent symptoms from arising. For those of you already having problems despite your best efforts at prevention, or those of you whose pregnancy and childbirth occurred years ago, let’s explore the burning issue that brought you to the bookshelf in the first place: how to alleviate your symptoms and feel better—starting today!

  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

  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

  How can you wear sexy underpanties when you’re always wearing a pad? I want to feel like a woman again.

  —Forty-one-year-old, before her operation for urinary stress incontinence

  I gave up my walking routine … and keeping dry on business trips—especially on airplanes—has become a major challenge. I’ve got to do something!

  —Fifty-four-year-old, during her first office visit

  Not long ago, a sixty-one-year-old woman came to the office, “at wit’s end” over her long-standing pelvic prolapse and urinary incontinence. She’d “had it” with pads, and fear over accidents had taken the joy out of her regular walking routine. In the corner of the room sat her thirty-four-year-old daughter, herself a nurse at a nearby hospital, with, on her lap, her own four-month-old baby. I shared a simple anatomy sketch and explained the nature of the symptoms the older woman had experienced for the past thirty years. After we made a few arrangements for testing, our visit drew to a close. As I headed down the hallway, her chart in my hand, I felt a tap on my shoulder. It was the daughter. She’d been keeping her baby fully occupied with a rattle and a bottle of milk throughout the visit, as she closely followed my discussion with her mother.

  Now she asked if she could have just another moment of my time: “By the way … since my daughter was born, I’ve been leaking sometimes when I cough or bend down to lift her up from the stroller. Is there anything I can do to avoid all this stuff my mom is going through?”

  It was a question that most women with these early problems never find the opportunity to ask. I was glad this woman had—that along with caring for her daughter, she was also thinking about herself. After all, it had taken her mother a full three decades to seek help. Yes, I answered, there were things she could do to feel better, to avoid a bigger problem and “all this stuff” that her mother was facing. The way she worked and exercised, her choice of foods and beverages, her bathroom habits—all of these might have an impact. Whether you’ve recently noticed a loss of bladder control or have been struggling with symptoms for many years, familiarize yourself with all that can be done at home, in the office, and in the operating room to maximize your quality of life.

  The Four Types of Urinary Incontinence: Understanding Your Problem and Finding Relief

  TYPE #1: STRESS INCONTINENCE

  As a young girl, I remember losing urine when jumping on a trampoline. But since childbirth, it’s been a regular problem.

  —Forty-one-year-old, during her first office visit

  Although the symptom of stress incontinence (leakage at the moment of a cough, a sneeze, or other sudden physical stress) might not arise until years after pregnancy and childbirth, countless women can trace the physical changes setting the stage for incontinence back to their obstetrical past. According to a Danish study of more than three thousand women, two thirds of those with stress incontinence recalled that their condition began during pregnancy or just after childbirth. A study of nearly twenty-eight thousand women from Norway found that after just one childbirth, the risk of stress incontinence rose nearly threefold among those between the ages of twenty and thirty-four. According to a large study from the 1960s, 65 percent of women with stress incontinence first reported their symptoms during pregnancy, and 14 percent recalled that their leakage problems began during the postpartum period. Other studies have found that for women between the ages of thirty and forty-five, a history of vaginal childbirth carries a two-to-five-times higher risk of having stress incontinence.

  Even if you’ve never had a child, you’re not without risk for developing a loss of bladder control, particularly as you advance in age. Consider the survey of nuns that showed nearly half reporting some degree of urinary incontinence by the average age of sixty-eight. Although childbirth is the biggest factor leading to stress incontinence, it’s not the only one. So don’t swear celibacy or join the convent just yet.

  TIPPING THE BALANCE OF CONTINENCE

  To understand why stress incontinence becomes so common after childbirth, let’s take a look at the basics of continence. What allows you to have normal control over your bladder in the first place? Whether you’re coughing, lifting, or just trying to make it to the ladies’ room during a powerful urge, your ability to hold it in boils down to a simple requirement: the urethra must stay closed and maintain a pressure between its closed walls that is stronger than the pressure building up in your bladder. It’s similar to pinching the neck of a water balloon closed, to keep the water from leaking out. Simple, right?

  Unfortunately, it’s not so simple. Even before the physical stresses of childbirth, the maintenance of dryness is rather tenuous. Can you look back to childhood and recall a few times you laughed too hard at a slumber party and felt a dribble? Does the crossing-your-legs maneuver—womankind’s most ancient method of incontinence prevention—ring a bell? Do you feel that you’ve often just gotten by on preventing an accident?

  The illustration shows the components necessary for good control at any age: a well-behaved bladder and a healthy urethra lying upon a strong vaginal wall. When these conditions exist, you’ll have the best odds of creating enough pressure in the urethra to hold back the force of urine—even, for instance, when you’re challenged with a full bladder during a tennis serve. These optimal conditions can be difficult to maintain. The anatomy of the female bladder and urethra places women at higher risk than men for developing stress incontinence. In fact, men are born with several innate advantages for maintaining dryness until their latter years—a longer urethra and a firm prostate rather than a flexible vagina lying beneath the urethral tube. But still, why such a steep rise in problems among women advancing in age?

  Enter pregnancy, labor, and delivery—the likes of which men’s bodies never have to withstand. As you’ll come to appreciate, if you haven’t alread
y, the vagina, urethra, and bladder are among the areas of your body most exposed and susceptible to wear and tear through the process of childbirth. Like that last straw on the camel’s back, the changes that occur during pregnancy and childbirth are often enough to tip the balance that had been keeping you dry.

  STRESS INCONTINENCE: A MAJOR PROBLEM FOR YOUNG AND ACTIVE WOMEN

  According to a 2001 nationwide survey conducted by the National Association for Continence, and sponsored by Eli Lilly & Company, 40 percent of women with the condition report that their problems started before age forty.

  THE FLOPPY URETHRA

  If you’ve developed stress incontinence during or after childbirth, one particular anatomical change is the most common culprit: weakening of the vaginal wall that lies beneath the urethra and provides its main support. Doctors refer to this problem as urethral hypermobility—meaning that the urethra is too mobile due to weakening of the vaginal wall beneath it. For the sake of simplicity, we’ll call it the floppy urethra. It accounts for the largest number of stress incontinence cases in postreproductive women, and it’s very much a product of pregnancy and childbirth.