PREGNANCY AND CHILDBIRTH
You’ll find no mention of incontinence in prenatal classes or in parenting guides. But ask a soccer mom or baby boomer about ‘leaking, pads, and diapers’ in private, and you’ll likely hear a personal story or be shown a surgical scar. Among mothers of all ages, incontinence and other pelvic problems are common.
- Urinary Incontinence. The most common type of incontinence to affect mothers, UI affects 30-50% of childbearing women by age 40. Up to 63% of stress-incontinent women report their problem began during or after pregnancy.
- Fecal Incontinence. Defined as loss of control over gas or stool, fecal incontinence (also known as accidental bowel leakage or ABL) affects up to 25% of childbearing women, often resulting from injury during birth.
- Pelvic Organ Prolapse. This refers to weakening around the vagina, uterus, and pelvic floor—common types include cystocele (dropped bladder), rectocele (bulging rectum), and uterine prolapse (dropped uterus).
For too long, these problems have been regarded as inevitable costs of motherhood—but attitudes are changing. Life after childbirth does not need to include a routine of pads and liners. A woman should not have to constantly struggle with symptoms at home, work, the gym, or even in the bedroom.
Whether childbirth was easy or difficult, long or short, one fact holds constant: your body will never be exactly the same after pregnancy and delivery as it was before. And while learning ‘what to expect while you’re expecting’ is important, knowing what to expect afterwards is the key to prevention. Indeed, decisions made during pregnancy and childbirth may impact your bladder and pelvic function for years to come. A few areas of your body are particularly important:
- The perineum lies between the vaginal and anal openings, it is the area cut with an episiotomy. Injuries may create vaginal ‘looseness’ or bowel problems.
- Levator muscles provide key support for the pelvic organs—helping to maintain control over bladder and bowels. After childbirth, muscle strength is usually compromised.
- Pelvic nerves maintain strong and healthy levator muscles. Nerve injuries, especially common after a long or difficult delivery, are associated with incontinence.
- Connective tissues help to secure the pelvic organs in place. During childbirth they routinely stretch, tear, and weaken.
- Your pelvic bones have a unique size and shape, which may influence the physical ease or difficulty you might encounter with childbirth, and the extent of pelvic injury.
If you are pregnant, or even thinking about becoming pregnant, it is never too early to get your body in shape to minimize the physical effects of carrying a child.
Kegel exercises, also known as pelvic floor muscle exercises, can decrease incontinence, and your first pregnancy is one of the best times to learn about them. Not only because the need is so great—up to 70% of women have some leakage during or after pregnancy—but the muscles have not suffered the trauma of birth.
Another helpful activity is called the Perineal massage. It involves gentle stretching of the vaginal opening, and may decrease the risk of birth injury and pain afterwards.
Several aspects of childbirth that may seem inevitable are, in fact, choices to be considered. While easy to say but hard to enact, staying as relaxed as possible for as long as possible can greatly reduce pain of delivery. When stress hormones kick in and pelvic floor tension rises, pain or anxiety increases. The results can directly impact incontinence in the coming days and even for years to come.
Along with a relaxation strategy, there are other things you can explore to make childbirth less stressful on you and your child. There is no avoiding the fact that labor pushing introduces tremendous strain on the pelvic floor.
While there is no one ‘best’ method of pushing, you should know your options.
- Which position? Although lying down on your back (lithotomy) is most common, alternatives include squatting, sitting, sidelying, and standing. Certain positions might influence the risk of pelvic or perineal injury, such as back lying with legs strapped in stirrups.
- When to begin? Recent studies indicate by allowing the fetus to ‘passively’ descend through the birth canal with gentle pushing reduces the risk of difficult deliveries, forceps, and perineal injury.
- For how long? Prolonged pushing may sometimes increase the risk of pelvic nerve injury, fecal incontinence, and bladder dysfunction. You may wish to discuss reasonable limits for pushing ahead of time with your doctor or nurse midwife.
Other childbirth issues include surgical techniques such as episiotomy. This refers to the intentional cutting of the perineum during childbirth. Today it’s known that episiotomies are rarely of benefit in terms of preventing injuries to the pelvic area. However, ‘selective’ episiotomy remains an important tool and can benefit the immediate health of mother and child.
Obviously, big babies are associated with more severe perineal, rectal and pudendal nerve injuries, and incontinence. If you are carrying a macrosomic (9 pounds or more) baby, be sure to understand these issues.
While the use of a vacuum may be associated with less pelvic floor trauma, forceps delivery carries an increased risk for urinary incontinence and injuries to the anal sphincter and pelvic floor compared with spontaneous vaginal birth.
The ‘Cesarean by Choice’ debate is surrounded by complex medical, economic, and social questions. In parts of South America, cesarean rates exceed 90%, whereas trends in Europe have favored vaginal birth whenever possible, even if it entails a long or difficult labor.
Determining the right policy will require more research. In the meantime, know the facts.
- Consider the risks. Although a c-section is safer today than at any time in the past, it still carries potentially serious risks for mother and baby.
- Consider the benefits. Urinary incontinence, anal injuries, and pelvic prolapse are less common after cesarean. C-sections with the lowest incidence of injury appear to be those performed in the first pregnancy, before labor begins.
- Individualize your choice. Most obstetricians and midwives share the goal of a vaginal birth whenever the benefits outweigh the risks. In some cases, a difficult vaginal delivery may be more physically traumatic than a cesarean. For others, the exact opposite will be true.
What can be done after delivery to prevent problems?
Physical recuperation after childbirth is substantial—and too often overlooked. Alongside the diaper changes, you should take steps to rehabilitate your pelvic floor. As noted above, Kegels are vital to strengthening pelvic floor muscles and reducing risk of incontinence issues.
Pelvic floor muscle exercises will help to restore muscle function before it is permanently lost and lessen the symptoms of incontinence. Women who have difficulty performing pelvic floor muscle exercises on their own may find that biofeedback therapy with the help of a nurse specialist or physical therapist enables them to witness significant improvement in pelvic floor strength. Incontinence and pelvic floor symptoms almost always have solutions and shouldn’t be shrugged off as normal.
Immediately following childbirth, preventing perineal swelling helps restore your body to health. Ice packs and proper hygiene are employed to avert infection. Also, avoiding constipation reduces strain against the pelvic floor.