ONE LAST RULE: DON’T FEEL LIKE YOU FAILED IF IT DIDN’T ALL GO AS PLANNED
At the end of the day, only two things matter: a healthy baby and a healthy mom. By the time you’re watching him or her stumbling through first baby steps—not to mention strutting down the graduation aisle—the intensity and importance of the labor drama will have long since faded.
Beyond the Crossroads
Along the road of life, childbirth is the most fascinating intersection between medical science, public health, ethical choice, economics, and pure emotion. Keeping informed in this area of women’s health will help to ensure that your decisions are not steered by economics, politics, or personalities alone, but also by an understanding of benefits and risks, and informed choice.
Our views on childbirth are approaching a crossroads, and women’s health is nearing a fundamental change. As women live longer and more active lives, we will need to face the long-term repercussions of childbirth to the pelvic floor more squarely. As you’ve learned, they are often problems that attest to the extraordinary physical demands of pregnancy, labor, and delivery. Beyond the crossroads, decisions in the labor room will be reconsidered not only in medical terms but also with respect to economics, politics, and ethics. A healthy baby and a mother’s physical health will define success, and these significant health issues will no longer be casually accepted as normal. As women insist on more research into the physical consequences of their childbirth choices, we will gain a greater understanding of which pelvic-floor problems relate most closely to pregnancy, delivery, or both. Most importantly, we’ll improve our ability to prevent them. Beyond the crossroads—for obstetricians, urogynecologists, midwives, family doctors, and women of all viewpoints—lies a new and more complete vision of women’s health care.
APPENDIX A
Kegel Exercises, Biofeedback, and Other Techniques to Strengthen Your Pelvic Floor
My mother had this same problem and finally had an operation that didn’t work at all. Is there anything I can do to avoid all of that?
—Liz, age forty-seven, mother of two
Whatever your age and wherever you may be along your reproductive timeline, maintaining the strength and health of the pelvic floor is a key strategy for minimizing pelvic-floor symptoms. A healthy pelvic floor can help to prevent all of the major problems discussed in the previous chapters—incontinence, sexual dysfunction, and in some cases, even pelvic prolapse. That’s why, right at the outset, even before you consider the wide array of more problem-specific treatments, you should devote some time and energy to improving the condition of your pelvic floor.
Learning Perfect Kegel Exercises: Working Out Your Pelvic Floor
Your pelvic floor won’t bulk up during a regular workout on the StairMaster, and well-toned levator muscles will rarely, if ever, attract flirtatious glances at the beach. But learning how to give your pelvic muscles a workout of their own can be the least expensive and most effective way to prevent and treat a number of postreproductive problems before ever setting foot inside the doctor’s office. And there’s nothing more attractive than that.
Kegel exercises (rhymes with bagel) first aim to increase your awareness of the muscles around the vagina, perineum, and bladder, then strengthen and tone them. In some Eastern cultures, pelvic-floor exercises have been taught as a rite of passage to young women during their transition to adulthood. In the Western world, they were introduced in the 1940s for treating stress urinary incontinence by their inventor, Arnold Kegel, a gynecologist who reported remarkable improvement in up to 93 percent of women. Kegel observed that pelvic muscle weakness was not exclusive to women with a previous vaginal delivery, but vaginal birth was the precipitating cause of muscle weakness for a great number of women. Over the decades since their introduction, Kegels have been successfully used for not only stress incontinence but also a handful of other postreproductive problems resulting from alterations in the pelvic-floor musculature.
Stress incontinence. By toning the sling and shelf of the levator muscles, pelvic-floor exercises can compensate for a floppy or thin urethra and significantly improve stress incontinence. Success is reported for around 50 percent of women with stress incontinence, making it the most popular reason to begin a pelvic-floor exercise routine.
The overactive bladder and urge incontinence. Kegel exercises can help to prevent overactive-bladder symptoms in several ways. First, as part of a bladder retraining regimen (see chapter 8), they can help to decrease the frequency of urination and number of nighttime voids. Second, because contracting the pelvic-floor muscles tends to relax the bladder, learning to quickly flex them can provide you with a tool for nipping unexpected bladder spasms in the bud. For treating urge incontinence, overall success rates of around 41 percent have been reported, with three good scientific trials showing improvement over controls. At the very least, developing your pelvic-floor muscles can help you hold it in and make it to the bathroom during close calls.
Anal incontinence. If you developed anal incontinence after vaginal delivery, Kegel exercises may increase your chances of regaining control over your bowels. One study demonstrated a strong preventive effect: among women who had experienced rectal injuries during delivery, pelvic-floor exercises lowered the risk of anal incontinence from 21 to 7 percent one year later.
Sexual dysfunction. Kegel exercises may be useful for various postreproductive sexual symptoms, including loss of sensation, painful intercourse, and the inability to reach orgasm. Strengthening and toning the muscles of the perineum and vagina may maintain vaginal sensation and fullness during intercourse, which can diminish after childbirth. For other women, the pelvic-floor muscles become overly tense and sensitive, like any other muscle cramp in the body. In that case, Kegel exercises (perhaps along with pelvic-floor physiotherapy or massage) might restore a more normal tone to the pelvic muscles and improve their ability to relax.
Prenatal prevention. Your first pregnancy is the ideal time to learn the art of pelvic-floor exercises, if you haven’t already. As mentioned in chapter 4, incorporating Kegel exercises into your prenatal routine can be a natural fit.
FINDING YOUR KEGEL MUSCLES: STARTING WITH THE STOP TECHNIQUE
Even if you’re familiar with the basic idea of Kegel exercises, odds are you’re probably not aware of the proper technique. First, you’ll need to locate the right muscles. The simplest way to start is the stop technique.
The stop technique is done while you’re emptying your bladder on the toilet. After you’ve been urinating for a few seconds, try interrupting your stream of urine with a strong squeeze of your vaginal muscles, then relax. Were you able to stop or at least slow the stream? If so, you’ve just found your Kegel muscles.
Try it one or two times more while you’re sitting, and this time shift your focus to avoiding any tightening of your legs, buttocks, or stomach muscles. Your goal should be to isolate the muscle groups of the vagina and pelvic floor. Straining these other areas will not only divert your mental and physical energy but can also generate high pressures in the bladder and encourage the urethra to open—working against your Kegel muscles and causing them to fatigue. If you’re not sure whether your stomach and inner thigh muscles are relaxed, try placing one flattened hand against each, so you’ll feel any accidental tightening of these non-Kegel muscles during your workout routine. When you’ve got it right, you should feel a squeezing and lifting sensation within the vagina, and a tightening around the anal area.
Got it? That muscle you’ve just tightened—the same that you’d use in the car when forced to wait just one more exit—should be the pubococcygeus—probably the most important Kegel muscle. Another muscle you may contract is the bulbocavernosis, located beneath the outer lips of the vagina and responsible for tightening up the vaginal opening. You may also feel the deeper pelvic-floor muscles contract.
Once you’ve used the stop technique to find these pelvic-floor muscles, be sure not to continue using it as part of your actual wor
kout routine. Regularly interrupting your urine stream can harm your bladder and even your kidneys over the long run.
Now empty your bladder, and try tensing these muscles while you’re lying on your back with your knees bent and feet flat on the floor, or sitting in a chair. Keep breathing while you do three to four repetitions in a row, with a short rest after each squeeze. Go slowly, as if your pelvic muscles were a freight elevator lifting a heavy load. Remember to avoid the temptation to squeeze your buttock, thigh, or stomach muscles.
If you had no luck locating your Kegel muscles with the stop technique, try lying down and squeezing tightly around a finger or tampon inserted into the vagina. Imagine that you’re trying to prevent the tampon or finger from slipping out, or that you’re trying to hold back a bowel movement. These muscles span your pubic bone and tailbone. Feel for a tightening or lifting sensation in that area.
If you’ve never exercised your pelvic muscles before, or if they lost much of their strength after childbearing, you might not have the ability to find them on your own; it may be difficult to even sense the appropriate muscles. If that’s the case, you’re not alone. It’s been shown that only around 50 percent of women can identify and effectively contract the correct muscles after verbal instruction, and that around 25 percent of them will develop ineffective or even counterproductive techniques. But don’t despair—learning pelvic-floor exercises might still be possible using special techniques and devices that you’ll learn about later in this appendix (see “Biofeedback” and “Vaginal Cones”).
LESSON FROM THE FAR EAST: YOGA FOR THE PELVIC FLOOR
It is claimed that certain yoga poses work out your pelvic floor in a way similar to the Kegel routine, though they’ve never been scientifically tested. Aswini mudra is one such pose that you might want to ask an instructor about. It begins in the sitting position, with a straight spine. The pelvic, vaginal, and sphincter muscles are tightened, as with a strong Kegel squeeze, while the rest of the body is relaxed. The pose is maintained for several breaths, then relaxed. With time and practice, extend the time of each pose, and let your urogynecologist know if it brings you any relief.
THE WORKOUT: MAKING THE WORLD YOUR PELVIC GYMNASIUM
Once you’ve managed to find your Kegel muscles, it’s time start a workout routine. First, choose a comfortable place where you can make some frightening facial grimaces without the least bit of shame. You can sit, stand, or lie down. Some women prefer lying faceup, with knees bent and feet flat on the floor and perhaps a small pillow tucked beneath the lower back. Body positions don’t make a critical difference in most cases, though you will most likely find certain ones help you to isolate the pelvic muscles, both mentally and physically, while keeping the rest of your body relaxed. For most women, standing is significantly more difficult than sitting or lying down with knees bent.
WEEK 1
With your legs slightly apart and your stomach and chest relaxed, gradually squeeze your Kegel muscles until they’re at maximum tightness, for three to five seconds. You should feel tensing around the anal and vaginal areas, and lifting of the whole area in and up. Focus on the vagina, urethra, and perineum, and once again imagine you’re driving in a car, this time with a full bladder and two exits to go. If you feel your thighs, belly, or buttocks tightening, focus on relaxing these muscles. Then completely relax everything for ten seconds, and feel the tension release. After the ten-second rest, start with another three-to-five-second squeeze.
Repeat this up to ten times, or until you start feeling the muscles fatigue. When did your muscles start to fatigue? If it was after only three repetitions, then that’s your starting point for the first week—try doing those same three repetitions twice a day. If you were able to complete ten truly strong squeezes during your first session, then you’ve started with a significant amount of pelvic-floor strength and can move on to a more aggressive routine of ten contractions, twice daily. If you’re developing muscle soreness, skip a session and cut the number of repetitions by half for the next day or two. Each Kegel session should take you no more than five minutes.
WEEKS 2 and 3
After the first week, increase your number of ten-squeeze sets. Anywhere from two to three sets each day, spaced at least twenty minutes apart, should be your goal. Try to increase the strength of your contractions each day until they’re rock-hard from start to finish.
WEEKS 4 to 6
Increase your squeeze time to a full ten seconds for each repetition, if you haven’t already reached that goal. Try to hold it just as strongly from beginning to end. Along the way, as you increase your exercise challenge, alternate your positions among lying, sitting, and standing for individual sessions. Try standing with your legs apart, which tends to be the most difficult position. You can also experiment a bit with the speed and duration of your Kegel contractions. Try some quick-flicker squeezes: rapidly contract and then completely release after only two seconds instead of the usual ten-second slow-hold clenches that you first learned. These flicks will both reinforce your familiarity with the correct muscle groups and increase your ability to produce a strong, quick contraction using your fast-twitch muscle fibers. Flicks can provide a useful insurance policy against leakage during moments of sudden physical stress (see “Pelvic-Floor Bracing,” below).
When you’re able to hold a strong contraction for ten seconds, repeating ten times, then you’ve reached the basic training goal. Continue with two or three sets of ten to twelve contractions—in other words, a range of twenty to forty daily squeezes—to maintain your strength. Try keeping it up at least three to five days each week. Congratulations! You’re buff.
KEEPING A PELVIC-FLOOR EXERCISE LOG
A simple daily log will help you keep track of your progress with pelvic-floor exercises.
How many sessions today? ________
How long was each session? ________
How many squeezes or repetitions per session? ________
How many seconds was each squeeze? ________
“HOW WILL I REMEMBER?”
Patients often ask what’s the right time and place to do their Kegel exercises, and the answer is surprisingly simple: any regular routine that you’ll actually keep up with and not abandon, is the right one. It’s no different than opening that membership to your neighborhood gym—you’ll have to realistically fit a pelvic-floor exercise routine into the rest of your busy schedule. As any gym member can testify, even with the best intentions today, good workout habits are tough to maintain through tomorrow and beyond.
The most reliable way to remember your pelvic-floor exercises is to link them to other daily routines. Since you can perform these exercises in nearly any place or position, your potential links are limitless. Try linking your exercise sessions to the same time of day or night that you’re nursing your baby, watching a TV sitcom, or riding the bus. If you commute to work by car, try Kegeling at red lights. If you ride the train, squeeze at the stops. If you’re a golfer, try a few flicks each time you’re waiting at the tee. Boring board meetings, bus stops, and chair lifts work equally well. One patient told me she’d performed a ten-minute pelvic-exercise routine at her kitchen table every morning for over ten years, while drinking her Folgers coffee and watching the Today show—now, that’s a patriotic American scene! As you make the world your pelvic gymnasium, just be sure to breathe and pay attention to your facial expressions. After all, the only real danger of Kegel exercises is accidentally displaying a bizarre-looking facial twitch or grimace during an important meeting, job interview, or romantic candlelight dinner for two.
EXPECTATIONS: WILL KEGEL EXERCISES REALLY WORK?
As with any other exercise program, pelvic-floor exercises will improve your symptoms only if you keep up with them regularly, and only if you’re patient. It often takes between six and twelve weeks to see significant results after beginning a Kegel routine, sometimes with a shorter time to improvement seen for urge symptoms. So, if you haven’t noticed improvement after
a few months, don’t throw in the towel quite yet.
The best results are often achieved when a nurse, doctor, or therapist supervises your first several workouts. Ongoing and structured pelvic-floor exercise programs—in other words, a series of regular office visits or group exercise sessions—are even better, with much higher rates of success and dryness. Cures may be attainable for over 30 percent of women, with improvement of symptoms for 60 to 70 percent. With only brief instruction, on the other hand, less than 20 percent of women will succeed. Two very important points: don’t spend more than ten minutes with your exercise routine, and don’t perform hundreds of contractions just for kicks. First, because overworking your pelvic-floor muscles is not of benefit; and second, because you’ll be likely to burn out. A slowly-but-surely approach will increase your odds of long-term success. Two or three sessions each week may be enough, especially if it’s a routine you’ll actually stick with.
While pelvic-floor exercises can work well for mild urinary incontinence and prolapse symptoms, they rarely provide a solution for more severe cases. You’ll be unlikely to transform constant leakage into total dryness with exercise alone; and if a thin-walled urethra is causing your incontinence, the odds of a cure from exercises alone are even steeper. You also won’t significantly improve prolapse that’s already bulging outside your body. But when done correctly and regularly, pelvic-floor exercises can always play a part in preventing and controlling early bladder, pelvic, and sexual symptoms. Best of all, they have no side effects, require no prescription, and won’t cost you a dime.
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