You’ll find no mention of pelvic prolapse, urinary or fecal incontinence in prenatal classes and little attention devoted to them in menopause guides. But ask a soccer mom or baby boomer about “leaking, bulging, pads and diapers” in private and you’ll be likely to hear a personal story, see a surgical scar, or be asked the question “you mean that’s not normal at my age?” Fortunately, incontinence and pelvic floor symptoms are finally gaining recognition as common problems that affect women you and old, ones that can severely diminish the self confidence and physical function of women trying to maintain full and active lifestyle diminish. In many cases, pelvic floor problems attest to the extraordinary physical demands of pregnancy, labor and delivery, though they often arise years or even decades after. Urogynecology is the first women’s health specialty devoted to the treatment of these disorders, and as such, is offering brand new perspectives on childbirth and it’s potential aftereffects. The lifestyle and childbirth decisions of today’s 30-year-old may impact key aspects of her physical function at age 40-60. Just the same, incontinence, prolapse or sexual dysfunction experienced by a 50-yr-old may relate to choices she made during childbirth, years before.
Incontinence and pelvic floor problems are not inevitable but common after childbirth. Generations of women have regarded incontinence and pelvic floor problems as inescapable “costs of motherhood”, silently accepting their loss of control and self confidence. Despite the fact that childbirth is a major risk factor leading to urinary incontinence, anal incontinence and pelvic prolapse, for most women these problems are either preventable or treatable. If you are an expectant mother or contemplating pregnancy, learning about what to expect when you’re expecting is important, but just as importantly, you should know what to expect over the years that follow and understand how to prevent problems in the first place. Pelvic exercises might lower your risk of incontinence after deliver. Do you know the risks and benefits of forceps delivery or episiotomy, and what their proper role should be? What are the effects of perineal massage and alternative pushing techniques? Did you know that the length of time you choose to push might relate to your risk of incontinence later on? When is choosing a cesarean a reasonable option to discuss with your healthcare provider? If you’re already a mother and are contemplating having another child, you may be wondering if mild problems with bladder control will get worse. You should be aware that normal life in years ahead is not a daily routine of pads and liners, or a struggle with symptoms that diminish your enjoyment of life at home or work, at the gym or in the bedroom.
Which pelvic floor symptoms are most common after childbirth?
- Urinary incontinence: This affects 30-50 % of mothers before age 40. Among women experiencing stress incontinence after childbearing, up to 63% report that it began during pregnancy, where as 18% of women report some incontinence before pregnancy by their 3rd trimester over 50% have complaints. So even before giving birth, pregnancy alone can be enough to cause the problem. And if you already had incontinence before pregnancy, during those nine months your symptoms are likely to become worse.
- Anal Incontinence: Loss of control over gas or stool affects up to 25% of women who have given birth. Not all cases of anal incontinence are caused in the labor room, but childbirth injuries are indeed the key factor predisposing women to this problem.
- Sexual Dysfunction: Physical changes caused by childbirth affect female sexuality more often than most women are aware-manifested as pain,loss of sensation, or problems with orgasm. Six months after childbirth, roughly one quater of women after a first vaginal birth experience diminished sexual function and higher rates are seen following forceps or vacuum delivery compared to ‘spontaneous’ vaginal birth.
- Pelvic Prolapse: After childbirth, the vast majority of women will develop some degree of weakening around the vagina, uterus and pelvic floor, at least enough to be visible to a doctor during a pelvic exam. Although a minority of women with mild changes to their pelvic supports will be bothered by symptoms, by age 80 up to 11% of the overall female population will undergo major surgery for prolapse or incontinence. Common types of prolapse include cystocele (dropped bladder), rectocele (bulging rectum), and uterine prolapse (dropped uterus).
Which Key Body Parts Might Be Affected?
- The ‘perineum’ is the span of tissue between the opening of the vagina and the anus. It represents the connection point for several muscles that form the opening of the vulva and vagina. The perineum is visible externally, and represents the tissue intentionally cut during an episiotomy.
- The levator muscles provide much of the foundation of your pelvic floor. Their condition can strongly influence the way you feel and function, as they provide the major support for the uterus, vagina, bladder and other pelvic organs-and are important for maintaining control over the bladder and bowels. After childbirth, loss of strength and detachment from their supports are commonly seen.
- Pelvic nerves are responsible for maintaining pelvic floor muscle strength- as the levator muscles depend upon a healthy nerve supply to maintain their strength, position and tone. One nerve called the ‘pudendal’ is particularly important- and injuries to this nerve are associated with incontinence and pelivc floor symptoms after childbirth, and especially after difficult deliveries.
- Pelvic ‘connective tissues’ and ‘ligaments’ are tissues that help to secure the pelvic organs to their proper locations in the pelvis. During childbirth they routinely stretch, tear, and weaken.
Which Stages of Childbirth Affect the Pelvic Floor?
It is rarely appreciated that labor and delivery are among the most important physical events in a woman’s lifetime. But the fact is, whether childbirth is easy or difficult, long or short, one fact remains constant: your body will never be exactly the same after pregnancy, labor and delivery, as it was before hand.
All stages of pregnancy and childbirth have implications for the pelvic floor, to some degree. For instance, when the widest part of the fetal head secures itself within the pelvic cavity, the fetus is said to have become ‘engaged’. Some women may suddenly feel they’ve begun to ‘carry lower’. When engagement occurs in a first pregnancy, it’s considered by some practitioners to be a sign that a ‘good fit’ exists between mother and baby-perhaps reflecting an easier labor and delivery ahead. What if, though, you’re past the due date of your first pregnancy and the baby’s head is still unengaged? According to some obstetricians, this may represent an early warning that your pelvic shape and your baby’s head aren’t an ideal fit, and that you might be at a higher risk for a long or difficult labor, or one that fails to progress to successful vaginal delivery.
Labor’s ‘first stage’ begins when uterine contractions become painful and frequent and the cervix begins to open. When the cervix is fully opened you have entered the ‘second stage’ of labor, which ends with delivery of your infant. At that point, most women are instructed to start pushing, encompassing the most physically stressful part of labor for both baby and mom. This involves a tremendous amount of stretching and compression throughout the most important pelvis areas: vagina, bladder, urethra, muscles and nerves.
How is the Vaginal Opening Affected by Childbirth – And by Episiotomy?
Injuries to the perineum and vaginal opening affect 35-75% of women during vaginal birth. Even after careful repair, permanent weakening may create vaginal ‘looseness’. Some women notice a bulging sensation near the vagina and rectum, or loss of sensation during intercourse. When the anal area is involved in the injury, it can lead to incontinence of gas and/or stool.
‘Episiotomy’ refers to an intentional cutting of the perineum during childbirth. Aside from cutting the umbilical cord, episiotomies are the most common obstetrical operations performed. Although episiotomies have an important place in the labor room, several studies have indicated that they may increase the likelihood of maternal bladder, bowel and pelvic floor problems after. As a result, the general trends have favored the strategy of avoiding episiotomy whenever possible.
Can Incontinence and Prolapse Occur, Even if I Never Gave Birth?
Pelvic floor problems, even incontinence and prolapse, absolutely can occur even if you’ve never had a baby. Up to 47% of women with no previous pregnancy report some degree of incontinence by age 68. And although the ‘Women’s Health Initiative’ showed previous childbirth to be associated with significantly higher rates of pelvic prolapse later on, 19% of women with no previous delivery also had prolapse.
Do ‘Big Babies’ Increase the Risk of Problems?
“Macrosomia” is associated with more likely occurrence of perineal injury and episiotomies, nearly 2 1/2 times the usual risk of rectal injury, and a higher risk of pudendal nerve injury. One study that delivery of a newborn weighing more than 8.8 pounds carried twice the ideal risk of urinary incontinence later on, and a higher risk of having to undergo later surgery to correct the problem. If you are found to be carrying a very large baby, it would be appropriate to discuss these issues with your doctor or midwife.