Few moms talk about incontinence and prolapse, but such "plumbing problems" are common after delivery.
Giving birth to my older daughter, now 6, required six hours of pushing. During my postpartum checkup, my doctor told me that my pelvic-floor muscles seemed lax and I might want to see a physical therapist about strengthening them. At first, I scoffed at the idea—who had time for P.T. appointments with a newborn, and how would I exercise those mysterious, invisible muscles anyway? Then my doctor told me, "If you ignore the problem, it could lead to incontinence." That got my attention.
Like me, about 10 percent of women who give birth vaginally each year experience an injury during labor and delivery that can potentially result in pelvic-floor disorders; these include urinary and fecal incontinence and pelvic organ prolapse (when the uterus or bladder drops into the vagina). "Twice as many women suffer a major injury to the muscles near the birth canal per hour of labor as suffer injuries per hour of play in major college athletics," says John O.L. DeLancey, M.D., director of the Pelvic Floor Research Group and a professor of obstetrics and gynecology at the University of Michigan, Ann Arbor. Though experts aren't sure what causes pelvic-floor disorders, giving birth vaginally is linked to far more problems than having a Cesarean section. Use of forceps compounds the risk. In fact, DeLancey says, "What's most associated with muscle damage is a forceps delivery."
Injuries happen more frequently during a woman's first delivery, although problems can arise from subsequent births. Your risk of developing incontinence rises only slightly if you have given birth more than once, but having several children boosts your odds of developing the more serious problem of prolapse. For example, delivering one baby vaginally makes you four times more likely to have pelvic-organ prolapse, while having two bumps your odds up eight times, and bearing three babies jumps your chances up 10 times.
Some women blame pelvic-floor problems on having a vaginal birth after a C-section (VBAC), but this is not the case. "A VBAC is like any other vaginal delivery," explains Mark D. Walters, M.D., a professor and vice chairman of gynecology at the Cleveland Clinic in Ohio, adding that the reason a woman had to have a C-section might cause a problem when she delivers vaginally later. For instance, a woman with a tight pelvis would avoid trouble during delivery by undergoing a C-section. However, if she has a subsequent vaginal delivery, she might then have a problem. So any damage that occurs is not the "fault" of the VBAC itself but the result of delivering vaginally.
Preventing the problem
There is controversy over scheduling a C-section solely to avoid pelvic-floor disorders. "I am very much against everyone having C-sections," says DeLancey, who points out that for every 10 C-sections performed, only one case of pelvic-floor injury would be prevented.
Walters, who is the chairman of the American College of Obstetrics and Gynecology Committee on Urogyn-ecology, says women who are at high risk for pelvic-floor damage—either because they have a tight pelvis, a maternal family history of prolapse or incontinence, or their babies are really big—might want to consider a planned C-section. But he agrees with DeLancey that too many C-sections would be required to make a difference.
Doing Kegel exercises—contracting and relaxing the muscles surrounding the vagina, as if you're stopping the flow of urine—"can't hurt and might help," says DeLancey, who adds that Kegels help speed healing of the pelvic- floor muscles after delivery. "I'm a strong advocate of pelvic-muscle training, but I'm not saying those exercises will prevent injuries," he says.
Since smoking and being overweight can contribute to incontinence, being at a healthy weight and quitting smoking before getting pregnant might reduce a woman's risk, says Rene Genadry, M.D., medical director of the Women's Pelvic Center at Johns Hopkins University at Green Spring and co-author of A Woman's Guide to Urinary Incontinence (Johns Hopkins University Press). A study recently conducted in Norway found that mothers who were 35 or older and had a body mass index greater than 30 had a higher risk of urinary incontinence than women who suffered incontinence during pregnancy.
Fixing the damage
If you suspect a problem after having a baby, discuss it with your OB-GYN within the first couple of months (see "5 Signs of Trouble," below). Your doctor may refer you to a specially trained physical therapist, as mine did. (If she is unable to help you with this, contact the American Physical Therapy Association at apta.org.) Most P.T.s use biofeedback, positioning either an internal probe or electrodes on the perineum—the area between the vagina and anus—to provide visual awareness on a computer screen of your pelvic muscles working. "Because you cannot see the muscles contract and because they do not contract into or against anything, they are harder to isolate than other muscles in the body," explains physical therapist Patti Koehler, co-owner of the West Portland Physical Therapy Clinic in Oregon.
If physical therapy doesn't work, surgery to attach a small "sling" to the pelvic muscles can be performed; this takes 20 to 30 minutes and requires only light sedation and local anesthesia. Prolapse surgery takes one to two hours and requires general anesthesia. However, before considering surgery, doctors suggest waiting until after your baby's first birthday to see how much healing occurs naturally. Success rates are good—there's an 80 percent to 85 percent chance of eliminating "leaking" when you sneeze, for instance, says Walters.
As for me, hearing my doctor say the word "incontinence" was motivation enough to seek help right away. I started working with a physical therapist the following week, and I'm proud to say I'm leak-free, even when I run. And as a marathoner, that's saying a lot.
5 Signs Of Trouble
Signs of a pelvic floor-disorder range from slight to severe. Here are symptoms to look for up to 12 months postpartum, according to Mark Walters, M.D., head of gynecology, urogynecology and reconstructive pelvic surgery at the Cleveland Clinic:
1) Urine leakage when you sneeze, laugh, cough or exercise.
2) Difficulty pushing out a bowel movement or feeling pressure on your perineum when bearing down.
3) Trouble keeping a tampon in.
4) A feeling of looseness in your vagina during intercourse.
5) The sensation that something is dropping down in your vagina during activities or intercourse, especially when you are on top.
For step-by-step instructions on how to do Kegels, go to fitpregnancy.com/kegels.