Incontinence: the traumatic result of vaginal birth that dare not speak its name

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To hear natural childbirth advocates tell it, vaginal birth is an unalloyed good.

The truth is rather different. Normal vaginal birth can lead to a lifetime of serious, embarrassing and life altering problems. Incontinence, among other issues, is an entirely natural consequence of an entirely natural vaginal birth.

As a newspaper piece from New Zealand notes, We need to speak more honestly about traumatic births:

Incontinence is an entirely natural consequence of an entirely natural vaginal birth.

It ruins sex lives and destroys marriages, stops women from engaging in physical activities and even prevents some types of paid work. Although common, many women are so embarrassed by it that even their partners and closest friends are unaware of the problem.

It’s the injury that can result from a vaginal birth.

New research presented last week at the International Continence Society in Montreal about the psychological consequences of traumatic vaginal birth suggests that between 20 and 30 per cent of first-time mothers having a vaginal birth will suffer severe and often permanent damage to their pelvic floor and anal sphincter muscles. There can also be major psychological consequences of traumatic vaginal birth.

Conditions range from life-long urinary and faecal incontinence, painful sex, genital prolapse, body image problems and emotional trauma.

To understand why these problems develop we need to understand how the pelvic organs are held in place.

Ever wonder why the uterus doesn’t fall down through the vagina? It’s partly because of ligaments that hold it in place in the pelvis, but it’s mostly because of the muscles of the pelvic floor that form a sling to hold the organs up.

Here’s a classic view of the of the female pelvic floor seen in many anatomy textbooks:

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The view is from the top down with the spine at the back (bottom) of the image, the pubic bone in the front (top) and all the organs have been removed.

You can see how the multiple muscles of the pelvic floor form a sling and that sling perforated by three tubes, at the top is the urethra, which carries urine from the bladder to the outside, the middle tube is the vagina, and the tube underneath is the rectum.

Now imagine a baby’s head, 10 centimeters in diameter, passing through this sling. It’s obvious that the fetal head is going to dramatically stretch, distort and possibly tear the muscles that surround the vagina. They will literally never be the same again. Where once the space between the muscles of the pelvic floor was only large enough to accommodate three relatively small tubes, now that space has been stretched tremendously.

Keep in mind that we are talking about internal muscles, not the tears in the vagina that occur externally (1st, 2nd, 3rd and 4th degree tears). External tears produce visible external damage. It’s not difficult to understand that a 3rd degree tear (a tear through the sphincter muscle surrounding the anus, which is locate below the level of the pelvic floor) makes continence of flatus (gas) and stool impossible. The anal sphincter is under voluntary control, but if it is torn, the anus cannot be closed to the prevent the release of the contents of the rectum. Stitch the sphincter muscle back together again and continence will be restored.

Injuries to the muscles of the pelvic floor take place at a deeper level, not visible externally, and not accessible to repair. The most common injury to these muscles is stretching and kegel exercises are designed to strengthen the muscles and thereby tighten them. But the injuries can be more severe than stretching. The muscles themselves can be torn away from the pelvic bones.

Midwife and co-author of the new research into psychological consequences of traumatic vaginal birth Elizabeth Skinner spent two years gathering and analysing the experiences of women who have suffered traumatic vaginal births.

“Women who have sustained vaginal birth trauma often have avulsion of the levator ani muscle. This is a disconnection of that muscle from the pelvic bone resulting in prolapsed organs. Women just put up with this “hidden injury” as they are too embarrassed to discuss symptoms with clinicians who frequently do not believe them,” Skinner says.

No amount of kegel exercises can repair pelvic muscles that are torn. When these muscles are torn, the pelvic organs can slip through the middle of the pelvic floor. This is known as prolapse. When a pelvic organ like the bladder prolapses, it distorts the relationship between the sphincter that controls release of urine from the bladder into the urethra. Although the sphincter itself has not been damaged, it nonetheless prevents the woman from “holding” urine. It works well enough that urine doesn’t constantly dribble out of the urethra, but when the intra-abdominal pressure is dramatically increased as occurs during coughing and sneezing, urine squirts out (stress urinary incontinence).

The damage may not be immediately apparent. It may not appear until menopause when ligaments are weakened by the lack of estrogen and the pelvic organs begin to drop between the muscles. A woman who has had no problem for 20+ years after the births of her children may gradually develop uterine prolapse and/or incontinence as she enters menopause.

How often does damage to the pelvic floor occur?

Professor of Obstetrics & Gynaecology, at the University of Sydney’s Medical School Hans Peter Dietz says that damage from vaginal birth is much more widespread than generally assumed.

“Only about 25 per cent of women get a non-traumatic normal vaginal delivery that did not do serious damage to their pelvic floor or their anal sphincter’, says Professor Dietz. ‘And this is on first time mothers. If we did this kind of analysis on women who try for a VBAC (vaginal birth after Caesarean) it would probably be as few as 10 to 15 per cent.”

In other words, up to 75% of women who have a vaginal birth will end up with some permanent damage to the muscles. The likelihood of damage rises dramatically with the use of forceps for obvious reasons. Putting forceps into the vagina and around the baby’s head creates a larger diameter than the baby’s head alone.

In our efforts to reduce the C-section rate, we’ve made the problem worse.

The policy to reduce caesarean births has lead to an increase in the use of forceps during vaginal deliveries and a tolerance for longer periods of pushing during the second stage of labour, both of which increase the risks to the mother and baby.

“The forceps rate has doubled in NSW over the last 10 years. At some hospitals quadrupled,” says the University of Sydney’s Professor Dietz. ‘That means much, much more damage is done than ten years ago — in some instances twice as much. This is largely a result of the attempt to reduce the caesarean births rate.”

One way to completely prevent damage to the pelvic floor is to have a C-section on maternal request.

Elizabeth Skinner and Professor Dietz are not against vaginal births; in some cases a vaginal birth is the best option. They also note that a caesarean section is major abdominal surgery and carries its own risks.

However women who have big babies, are short in stature, have Asian heritage, and have a family history of difficult births should be informed of their greater risk of trauma if they have a vaginal birth. And all women should be given the choice to make an informed decision for themselves.

Urinary and fecal incontinence, uterine prolapse and painful sex are not trivial problems. They can be life altering and the are the entirely normal consequences of completely normal vaginal birth. It’s hardly surprising that many women want to avoid them and it’s deeply unfortunate that in a society where vaginal birth is valued more than C-sections, no one warns women that they can occur.

  • Kristen Nelson Sella

    I think it would be helpful if you included the percentage of women who have incontinence after cesareans. I have had two csections (the first scheduled for fetal macrosomia, the second after a TOLAC where I got to 8.5cm but baby was still -2 so we went for the csection, I was no where near pushing). 4 years post baby and I am having problems with stress incontinence (sneezing or coughing, had a recent cold that really brought it to light) and I feel a bit deceived by all the pro elective cesarean information out there that indicates that I should have avoided this by not having a vaginal birth.

    • Erica A.

      I wonder if that is from the c-section or from the pregnancy?

    • AllieFoyle

      Lots of things can contribute to incontinence, including pregnancy itself. You can certainly have problems without having given birth, but those problems have more to do with stretching, tissue/ab weakness, repeated infections, and/or pressure, and they can often be successfully addressed with things like kegels. Vaginal birth can cause discrete structural and/or nerve damage that can be more severe and difficult to repair, in addition to issues like prolapse and rectal damage caused by direct injury to the tissues.

    • Wombat

      While I’m sure a c-section can be a factor (especially if there is any rush or a less than ideal incision placement), it is entirely possible to have incontince and urge issues unrelated to childbirth. Even at a (relatively) young age. I unfortunately know from experience. And lemme tell ya, the article is unfortunately right on the money on the blank-ass looks I get from most OBGYNs and GPs as they try to combine and rectify ‘nulligravida nulliparous’ and ‘stress incontince/urge issues’. Still searching for my ‘dream’ OB unfortunately :c

  • Grace Adieu

    “They also note that a caesarean section is major abdominal surgery and carries its own risks.”

    Sure. But scheduled c-sections are very safe, as “major abdominal surgery” goes, and prolapse/pelvic reconstruction surgery presumably also carries its their own risks.

    • The Computer Ate My Nym

      It should be noted that “major abdominal surgery” is redundant: any surgery that involves the abdomen is considered major surgery. That simply differentiates it from minor surgery, which is things like having a mole removed. It doesn’t mean that life threatening surgery. (Anymore, anyway.)

  • StephanieA

    My mom and I were talking last night and it made me think of this post. I’m her oldest child, she wanted a natural birth. 36 hours into labor she had a c section. She pushed for 4.5 hours, a lot of that time I spent sitting right at the perineum (they tried a vacuum, so I know I was pretty low). After her section she had severe rectal pain for weeks, her doctor kept dismissing it as hemorrhoids. She finally had surgery for a torn rectum that had become infected two months after delivery. This made me angry. It’s like women’s pain isn’t to be taken seriously, and pain involving childbirth is waved away and looked at as ‘normal.’ She says it still hurts every time she has a bowel movement (more of an aching). I can imagine there are millions of women suffering from the effects of childbirth in silence because these issues aren’t ‘important.’

    • AllieFoyle

      It makes me angry too. And there are so many people out there who view any non-cesarean birth as a positive. What is positive about this? Why aren’t childbirth injuries seen as significant?

  • Maestro_Wu

    Since this is an educated group here, are there any studies on the efficacy of laser vaginal rejuvination to treat the post-vaginal delivery problems like incontinence? I read something on Jezebel about the procedure (http://jezebel.com/giving-birth-ruined-my-vagina-so-i-got-a-new-one-1725046810) but of course the internet folklore cannot replace medical science.

    • Dr Kitty

      Vaginal rejuvenation (yuck) is the marketing term, not the medical one.

      Anterior repair will treat bladder prolapse and can reduce the diameter of the vagina. It may or may not improve incontinence and sexual function.

      Put it this way, if you have incontinence or sexual dysfunction, see a urogynaecologist specialising in pelvic floor repairs, not a plastic surgeon who promises to make you feel like a virgin again.

    • Wombat

      The link is dead (or doesn’t like mobile, idk) but is this the Mona Lisa Touch? There is a practice near me schilling the daylights out of theirs. If aome women get relief, even if placebo, I am happy for them. But the combination of $$$$ and reduced FDA standards for devices leaves me heavily skeptical.

  • Gatita

    OT but brilliant: Man Who Has It All

    The gender-bending satire account pokes fun at the advice working women are bombarded with on a daily basis. From how to dress and act in order to be taken seriously, to how to handle the “triple duty” of work, kids and relationship, this account turns the kind of advice women are used to hearing around on men.

    • Who?

      I am a little in love with that man.

      So long as we keep talking about childcare, housework and the ‘triple shift’ like they are women’s issues, we are nowhere.

      I was told recently at a networking function that I should wear my wedding ring, so my ‘availability’ could be better scoped by men like the one I was talking to. He looked a little taken aback when I told him that my availability, at least so far as he was concerned, bore no relationship whatever to my marital status.

      He won’t be hiring me anytime soon.

      While that sense of entitlement is alive and well, women are in trouble.

    • LizzieSt

      That is brilliant! It really highlights the ridiculousness of much of the advice given to women by the media, and why I gave up reading women’s magazines years ago. I don’t need to hear about how I should have more body confidence but also should lose weight, and how I’m beautiful the way I am but oh no I’m destroying my skin with the wrong skincare routine! Now go buy this $180 skin cream. (a real article, btw) And then learn 5,768 ways to get a man, but once you’ve got him, oh you know husbands, they will never help you with housework or the kids or anything, but there’s no point in saying no to all that and working towards a better arrangement because THAT’S JUST THE WAY MEN ARE, am I right?

      I’m done with it all. Done.

    • MaineJen

      LOVE

    • Wombat

      Be sure to check the other one linked (@honesttoddler) too. Both brilliant.

  • Chi

    Is it just me, or is this the biggest argument against ‘intelligent design’ ever? Because it clearly is NOT intelligent to push something the size of a small (or medium or large!) melon through an opening that usually only stretches to accommodate something the size of a few fingers.

    And people wonder why I’m an atheist >_>

    • MaineJen

      It’s our fault for wanting to walk upright…

      • Chi

        Hahaha, you’d think a divine creator would’ve seen that coming and adapted us for the process…

  • StephanieA

    I have had stress incontinence with both pregnancies. It started earlier with this pregnancy; I was at the aquarium with my son a few weeks ago and sneezed and literally peed down my leg (I was wearing a dress). It was embarrassing. It started during my first pregnancy, so maybe it’s more due to pregnancy than vaginal delivery? My son was born vaginally with minimal pushing and one tiny tear. The incontinence went away mostly after delivery. I’m wondering if mine is mostly pregnancy related and delivering a certain way might not help anything?

    • theadequatemother

      The way the upper urinary sphincter works is that the amount of pressure to overcome it varies based on the angle of the urethra. Pregnancy chafes that angle and can increase SUI. Vaginal birth can tear the fascial supports for the urethra and make it hyper mobile. Hyper mobility due to tissue damage is not the same as a momentary change in angle which is what you are describing. Hyper mobility due to tissue damage also doesn’t get much better with kegels because the muscles and their fascia are torn/ damaged. It’s like telling someone with a biceps tendon tear to do bicep curls to strengthen their arm. It just doesn’t work that way.

      • StephanieA

        Thanks for your response. I’m hoping since the incontinence pretty much goes away when I’m not pregnant that it won’t be an issue.

      • KarenJJ

        “Hyper mobility due to tissue damage is not the same as a momentary change in angle which is what you are describing. Hyper mobility due to tissue damage also doesn’t get much better with kegels because the muscles and their fascia are torn/ damaged. It’s like telling someone with a biceps tendon tear to do bicep curls to strengthen their arm. It just doesn’t work that way.”

        Mind blown. I’m going back to ask my GP. Thanks.

  • Inmara

    Thank you, Dr. Amy for discussing this often forgotten topic! I was aware of importance of Kegel exercises prior and post birth but I never knew that there are so much women affected by pelvic floor damage and incontinence. Turned out I am one of them – all was okay first weeks after delivery but now I’ve got stress incontinence. Hope that Kegels will help to reduce it and it will become less annoying (not fun when you have to haul heavy stroller up and down several staircases every day). And do I have to say that this condition never got mentioned during prenatal visits and classes, during hospital say and also in leaflets given out in hospital? (but they were full of lactivist propaganda, of course)
    And hemorrhoids, how about those? I read somewhere that around 25% percent of women develop these during pregnancy and post birth, fortunately it’s mostly temporary condition but painful, embarrasing and annoying nevertheless.

    • Chi

      I have stress incontinence now too. Started about 6 months after my daughter was born and is still ongoing. Doesn’t happen ALL the time, but I’m now really wary when I have to cough or sneeze. Last week when I had a chest infection and was coughing non-stop was REALLY fun…not.

      And yes, NO ONE ever told me that that might happen. It was all ‘oh just do your kegels, you’ll be FINE.’

      Hemmorrhoids are also a problem. I got them in my last trimester and actually had to have them removed surgically. But no, that’s never mentioned in the birthing classes either. The great thing was, because I was pregnant, they used a spinal anesthetic instead of putting me under general, simply because it was less risky to the baby. And I was checked out by a CNM before I even went into the operating room and then again when I came out. Then I went up to the maternity floor until the spinal wore off so they could continuously monitor baby (who actually weathered the whole thing better than I did lol). It was amazing, I was treated like such a star that time.

      The thing is, people don’t like talking about the ‘icky’ side of pregnancy. So no one warns you about these things. But when my daughter is all grown up and thinking of starting a family, you bet I’ll warn her. So she can have all the facts. If I had known the risk of damage, I may have requested a c-section. Tempted to do so with the next one, whenever that occurs lol.

      Thanks Dr Amy. It’s so good to know that it’s not an uncommon problem and that many women suffer problems post-pregnancy.

    • Sarah

      Oh yes. Fortunately no incontinence here, but I’ve got two of those little blighters right now. Annoying as hell!

    • Lena

      I know doctors don’t want to scare patients unnecessarily, but I find it incredibly condescending that they withhold this information from pregnant patients. When my cousin was pregnant she was really scared that she might need a c-section–not because of any NCB nonsense, just fear of surgery in general–and her OB would reassure her that c-section was possible but unlikely, and that she and baby would be fine regardless. She ended up with a c-section, everything went well, and when her ob went to check on her the next day and she told him she felt fine, he said something like, “And now you won’t have to worry about incontinence or prolapse!” He had made no mention of the possibility during her pregnancy, and I think telling her of the pros of a c-section would have gone a long way in reassuring her.

  • Amazed

    Poor Oregon midwives.

    https://www.thelundreport.org/content/state-imposed-obstacles-medicaid-payment-shutters-two-birth-centers

    “Cynthia Luxford is closing her Lincoln City birth center that opened 10
    years ago and “retiring” as a midwife after 29 years because her
    business could no longer absorb the loss of business from the Oregon
    Health Plan. Before the CCO experiment was launched, she would deliver
    45 babies a year, but that number has fallen to less than 20. The
    closure leaves the Central Coast without a birth center.”

    45. Babies. A. Year. And she thinks that’s so very much. Enough to have encountered all kinds of complications, enough to maintain skills she’ll need in all kinds of crisis… And I’m supposed to weep for poor birth center-less Central Coast? For real? WTFH?

    • Daleth

      How fantastic that she’s closing shop.

      I agree, delivering less than one baby a week and thinking you’re highly skilled based on that experience is ridiculous.

    • Monkey Professor for a Head

      When I was a med student, I spent a week on the labour ward and delivered 3 babies in that time. I suspect the midwives and midwifery students delivered far more in that time frame. At that rate, it would only take 15 weeks to deliver more babies than this midwife does in a year. That’s a scary thought.

      • Megan

        As a family practice intern, (NOT an OB intern), I delivered nearly 200 babies that year alone. This midwife is pathetic. There’s just no way you’d see enough to help anyone with complications doing 45 births a year.

    • Guest PDX
      • Daleth

        That is a fucking slap on the wrist. REVOKE HER LICENSE.

    • PrimaryCareDoc

      From the article: Augustine Colebrook, the midwife-proprietor of Trillium Waterbirth, said a state functionary at the Oregon Health Authority had required her and other midwives to submit extensive paperwork before getting compensated, a process that sometimes took the bulk of a pregnancy. If a woman was declined, or ended up delivering in a hospital, Trillium would receive nothing for its prenatal services. Additionally, she said the state had recently stopped compensating midwives who assist the primary midwife at a delivery.
      ______

      Cry me a fucking river. Welcome to Medicaid.

      • Amazed

        You know, my dentist doesn’t have anything to do with any payments provided by the public healthcare system. When I go there, I go with all the money in my wallet. Perhaps she offers installment plans, I don’t know. But she doesn’t want to do the extensive paperwork, so we pay in cash.

        The rub? Their practice is FULL of patients. They’re just this good, we want them and we pay them. Oh, and for problems that aren’t urgents, we sometimes wait for a few MONTHS to be seen and have the pleasure of paying the not-so-small sum.

        Perhaps Ms Colebrook should ask herself why she relies on Medicaid so much? Why isn’t she this sought?

        • cateye

          Well… to play the devil’s advocate (without looking it up), it might be the neighborhood she’s working in. Maybe the people in the neighborhood not only don’t have the ability to pay, but don’t have private insurance either. And those near that area won’t go into such a “rough” neighborhood.

      • Bombshellrisa

        Yeah, the state shouldn’t have to pay for two midwives who are there to hold the space and be hands off. I thought only evil OBs were in it for the money!

  • SporkParade

    Practical question: Can we predict how much damage will happen in subsequent vaginal deliveries based on a first vaginal delivery? And can we estimate how much damage has already occurred based on recovery time?

    • Daleth

      Nope. Anecdotally I’ve heard of women with one or two complication-free VBs behind them who then had a horrific tear (3rd degree or more) with their next birth.

    • CanDoc

      As an OB in practice for 10 years, the most severe pelvic floor damage is consistently done in the first delivery. I have only seen the extremely rare 3rd or 4th degree tear in second+ babies (maybe 2 or 3 ever), but I see a few (2-6, maybe?) per year in first-time moms my 200+ delivery per year Ob practice. If a woman has had a 3rd or 4th degree tear with a first delivery and has difficulty healing, problems with incontinence afterwards, or is concerned, we talk about the potential benefits of a cesarean section in the next delivery.

      • Blue Chocobo

        So if I’ve already had two or three vaginal deliveries, electively switching to cesarean for the next kid or two is unlikely to make a difference over continuing to deliver vaginally (other variables permitting, of course) in terms of pelvic floor damage? Or, put another way, all of an individual’s deliveries must be surgical to reduce their risk?

        • SporkParade

          Yes, this is my question exactly. The urinary incontinence and sexual dysfunction I experienced were temporary, but the fear that they might be permanent were a big contributor to my PPD.

          • Blue Chocobo

            Absolutely. On top of all the other negative stuff PPD screams into your psyche, a fear (hugely exacerbated by the PPD) of being dysfunctional and incontinent (with the PPD telling you your worth as wife/mother/person is tied to that) is another heavy burden to bear.

          • guest

            I had minor tearing during both of my 2 deliveries, but it still took months to recover fully from each and about a year and a half for pain during intercourse to go away. If there is a 3rd, I will have a c-section. 3 years of worrying if I would ever enjoy sex again is enough for me. My husband never acted like it was a big deal, but I obsessed that it was going to ruin my marriage.

      • Joy

        That’s reassuring if we ever have another, I suppose. I had forceps. It was the one thing I didn’t want, but they needed to get the baby out quickly and that was the fastest way. I am so grateful that two years after and I have yet to have any real issues, except for some stress leaking during what was the worst cough I can remember since I was 8 and was home ill for three weeks. I hold no illusions that I will remain so lucky after menopause. I did do kegels for years before getting pregnant though.

    • attitude devant

      CanDoc below is correct. There is actually a large body of research on this topic. The risk for urinary incontinence does not go up with subsequent deliveries—the first baby tears it all up. OTOH there’s also plentiful research on fecal incontinence suggesting that people with one third- or fourth-degree laceration can reduce their risk for future fecal incontinence by having and subsequent deliveries by c/s.

    • AllieFoyle

      I guess I’m the exception, but my later delivery was far more damaging than the previous one. I had enough problems after that delivery to want a cesarean the next time, but didn’t get one and had a really rough go– but by then I was older and had a much larger baby, which I imagine had an effect too. It’s probably just one of those things that depends on circumstances and luck. The statistics make it look as though it’s a one and done sort of situation, but maybe the numbers don’t show the whole picture or gradations of severity. It’s one thing to have a bit of incontinence when sneezing or something, but quite another to have more severe incontinence and symptomatic prolapse. I’m not sure the research accounts for those differences and the effects they can have on quality of life.

  • theadequatemother

    Vaginal birth ruined my pelvic function. After number one I couldn’t have an orgasm for upwards of six months and it wasn’t a breastfeeding lubrication issue. It seemed to take that long for the nerves to regenerate down their damaged axons. I guess 2.5 hours of ischemic time due to a babies head isn’t healthy for them.

    I had a transobturator sling put in about1.5 years after my second. I was so upset that I couldn’t exercise anymore. It certainly affected my self esteem and my ability to manage life stress (because exercise is how I cope).

    But sex still hurts and I still have to use estrogen cream during a certain part of my cycle because I have a skin bridge that leads to a lot of nasty introtal pain and also the arcitecture is such that when estrogen falls I get a fissure there. Predictably every month. I’m sensing trying to get this fixed but the urogyne tells me success rates aren’t high. Also the position of my cervix changed so that I no longer have enough vaginal canal length for a tampon unless I insert it just so so that is slips underneath…

    I also cannot ride my bike for long distances (anything over 30 min) because it’s like my insides are now on the outside due to gaping patois vagina and they rub. After a long ride I can’t pee without pain.

    So yeah. Thanks a lot vag badge.

    I’m sure things will get a lot worse as I get older. I’m still in the stage of grief called anger about it.

    • lilin

      Shit. I’m so sorry. That sucks and you have absolutely every right to be angry about it.

    • demodocus

      that sucks

    • attitude devant

      You know, I wonder when we are going to get to the point that women start to sue for lack of informed consent around vaginal birth. We as a culture do SUCH a con job on women around motherhood. It’s our greatest achievement, our greatest pleasure, blah, blah, blah…. Childbirth maims and kills. Why shouldn’t there be required disclosure around vaginal delivery?

    • toni

      I’ve got nothing really helpful to say just that I’m sorry you’re going through this. I have painful intercourse problems (not childbirth related just always have) and it’s such a drag. They are coming out with all kinds of cool stuff for women though like that Mona Lisa gizmo.. I’m sure they’ll have come up with something better for your issue by the time you hit menopause(?) I don’t buy this whole “they don’t care about women’s health problems/sexual function” stuff… women’s sexual problems are men’s sexual problems and vice versa.

      • attitude devant

        toni, trust me. They don’t care. Have you ever heard of lichen sclerosus et atrophicus? Of course you haven’t; it’s a skin disorder affecting the perineum of women, mostly older. Causes scarring, painful intercourse, intense itching. I’ve been treating it for over 30 years with the same moderately effective med….because NO ONE is granting money to study it. Wake up and smell the coffee.

        Oh, and the Mona Lisa gizmo? Find me some peer-reviewed research on that, because the drug rep who is trying to sell it to me has NONE.

        • theadequatemother

          I agree they don’t care. Bad a youngish healthy woman it took me quite a while to find someone that would help me now as opposed to physicians (and one absolutely horrible NP) that seemed to think I could just be disabled until I was done having children or solidly middleaged. One told me I should have a TOT now because I wouldn’t be able to lift my children for 6 weeks and that would interfere with being a “mom” too much. Or I was told I could just pee more often or take up swimming.

          I was also repeatedly told incontinence is the result of having kids “what did you expect?”

          • Ash

            I am sorry to hear that. Are there any docs in your area who have completed a fellowship in female pelvic medicine?

    • SporkParade

      Dang.

      • Karen in SC

        double dang. 🙁

    • fiftyfifty1

      I feel your pain TAM.

    • Laural

      This. Sucks. Have you seen ‘We’re the Millers?’ The part where the wife goes on about the ‘tampins hanging out like a roman candle’ is especially poignant. I also get so much worse during parts of my cycle. I may ask to try estrogen cream based on your post. Hate to have to share this embarrassing history/symptoms, again, with providers. I am scared of doing surgery as a provider told me the first one is the best one and I should hold off as long as possible.

      • Ash

        Laural–in the US there are doctors who have completed fellowship in female pelvic medicine. This means that in addition to urology or OBGYN, they have done 2-3 years more training specifically for female pelvic problems. You may want to seek out a doc with this specialty if you can.

      • AllieFoyle

        I was told that too, but frankly, I have no interest in suffering for years as a relatively young woman and so I had the repairs done anyway. I’m not going to have more children, so that part is moot for me, but even if I were I’d still have had it done, as I would absolutely make sure I got a c-section for any further deliveries. Having a repair is a legitimate medical reason for a section, so getting permission shouldn’t be an issue. If you want a repair and aren’t planning any further vaginal deliveries, I’d advise you to look into doing something. It’s your life and you shouldn’t have to suffer like this until menopause.

  • The Bofa on the Sofa

    Is pelvic floor reconstruction after childbirth where things like “vaginal mesh”es are used? I see commercials from the lawsuit industry about that all the time.

    • Megan

      Yes.

      • The Bofa on the Sofa

        So IOW, this is enough of a problem that there is an industry created involving lawsuits for problems encountered in trying to fix it.

        • Megan

          TBH, I’m not a urogynecologist, so I don’t really know enough about it to comment. I know I’ve had plenty of ladies referred for prolapse surgery and I don’t recall seeing an epidemic of problems from it, but I honestly can’t remember how many got mesh and how many didn’t (and the uros/gynes around here don’t often use mesh-maybe that’s why?). I’m not sure if it’s a real problem or something seized upon by lawyers, like the commercials that suggest to patients that they sue the manufacturers of blood thinners if they have a bleed while on them (a known risk, always weighed against the benefits by the prescriber, and nothing to do with it being a “bad drug”).

          • The Bofa on the Sofa

            Yeah, but I figure if they are advertising, that means there are enough women out there who have had adverse effects to be recruiting them. Has to be high enough to do a national advertising campaign. Indulge me to make up numbers, but if there are 1000 people with adverse effects, and if adverse effects are 1 in 100, that means that there are 100 000 women who had severe enough damage to warrant a vaginal mesh.

            That’s not small.

          • Megan

            It’s certainly possible. I just don’t know. I just don’t assume that because a law firm puts on a commercial that it means there is a problem caused by the drug/device. Sometimes there is, sometimes there isn’t. As in my example above, I certainly don’t think that Pradaxa causes bleeds more often than warfarin (in some cases it has shown less), but there’s a commercial to recruit people to sue it’s manufacturer. Why? Because Pradaxa is new and expensive.

          • The Bofa on the Sofa

            I don’t know or care about whether a problem is “caused’ by the mesh. What I am saying is that the fact that lawyers are chasing after mesh problems means that they must be common enough to chase after, and if the problems are common that means that non-problem meshes are even more common, which means that there are a lot of women with pelvic floor problems severe enough to require mesh to fix.

            So my point is that, the lawyers chasing vaginal mesh complications is, like the prevalence of Poise pads, a reflection of how common pelvic floor problems are.

          • attitude devant

            Oh, the mesh IS a problem. No question. Not every one has problems but the problems seen can be severe: mesh eroding into the vagina, bladder, urethra, small bowel and large bowel, causing chronic pain. I have seen all of these.

          • Medwife

            Yup. Very memorable complications. Those poor women.

          • Megan

            Ok, I didn’t understand what you were getting at but I do now. And I agree with you there. I do know that pelvic floor issues are a definitely a common problem. I just don’t know much about the mesh.

          • An Actual Attorney

            But the fact that they are advertising does tell us that there are enough patients with clotting disorders that it’s economically worthwhile for the lawyers to advertise. Liability may ultimately not be proven, but if you are just looking to figure if there are a lot of people with clotting disorders, the mere existence of the ads tell you something.

            IOW, there’s a market there.

            ETA: H&M clothes may not be better than Target clothes, but the fact that H&M advertises tells me a lot of people wear clothes. I have shopping on the mind.

          • theadequatemother

            My urogyne said the major problems are related to this one type of mesh that has the wrong tensile strength or thickness or lack of flexibility or something for urinary sling use. As I recall he stated that the company had the mesh for another application (probably hernias) and wanted to increase their market. The mesh I have has been used for upwards of 10 yrs without those kinds of issues. But…with de-estrogenization at menopause erosion rates increase so there is always a chance. I’m willing to take it because i want to run and ski and jump and not piss myself in the OR.

    • Laural

      Doctors advise against reconstruction if one is not done with childbearing.

      • Poogles

        Yep, which is why when I talked to my OB/GYN about my urinary stress incontince (which I’ve had for as long as I can remember) she asked if I was planning on having any kids (none yet). When I said yes, she said we would have to wait until after any births before putting in a sling or mesh or whatever. Until then, I just have to deal with it :-/

    • AllieFoyle

      Yes, and the mesh repairs can be a nightmare. There are repair techniques that don’t use mesh, but sometimes they fail, tissues can be weak (especially after menopause), etc. so they tried strengthening the repairs by adding mesh (probably also motivated by desire to increase mesh sales), like in a hernia repair. Unfortunately, a significant amount of the time the mesh erodes through the vaginal wall. It’s something you would not wish on your worst enemy.

      The smaller bladder slings have a better track record, but it’s a foreign object in your private bits — it’s not exactly ideal. These surgeries are surprisingly common considering how little awareness there is about them.

  • Bombshellrisa

    Has anyone else seen these? They sell them in the feminine care aisle.

    • Kerlyssa

      Was there supposed to be a link here?

    • Megan

      Is it like a pessary? I saw a commercial for them and wondered.

      • Bombshellrisa

        Yes, looks to be a pessary. They have different sizes. I worry that women will just buy these and suffer in silence or think it’s good enough as a fix and not talk to their doctor.

        • Dr Kitty

          Uh… Pessaries.

          I have one patient who had a very traumatic pessary change at the nurse-led pessary clinic.
          Since then the only person she’ll permit to change her pessary is me.
          I told her I was taking six months maternity leave and she would need to see another doctor while I was off.
          Her plan was to use extra topical oestrogen and to see me the first day I got back! I’m not sure if I entirely convinced her that this is NOT A GOOD IDEA.

          There was a very elderly female patient who had a ring pessary, and somehow when she became too frail and confused and her children moved her to a nursing home and changed her GP this fact got forgotten.
          That pessary stayed where it was and over the course of years embedded in the vaginal wall, became impossible to remove and eventually caused obstruction of the ureters. The whole sad story only became apparent once she was investigated in hospital for urinary problems and vaginal bleeding- not nice for a very confused ninety-something.

          I am not a fan of ring pessaries.
          And please, if you have one, tell your family about it so that it can be removed or changed if you forget…

          • Megan

            Oh yes. I’ve heard lots of forgotten pessary stories. Not nice…

          • Laural

            I have one- mine is the ring. Really? It is not embarrassing enough to have it I have to tell my family. Great. I’m laughing….

        • Megan

          “I worry that women will just buy these and suffer in silence or think it’s good enough as a fix and not talk to their doctor.”

          This was my first thought when I saw the commercial and thought they looked like an OTC pessary-type device.

  • KarenJJ

    Historically this must have been a huge issue. I still think we see parts of this in our culture with the traditional politeness to older women – helping carrying things, offering a seat, holding doors open etc etc. Nobody would have explained it would be due to the large amounts of organ prolapse, incontinence and pelvic issues from childbirth.

    • attitude devant

      The very first hysterectomies were done for massive prolapse. And women were so desperate to get relief that they took huge risks in having surgery. This was way before antibiotics, way before modern anesthesia. Quite the eye-opener.

    • Grace Adieu

      I also think that the practice of wearing corsets, especially by middle and upper class women, who were presumably more sedentary, was at least in part associated with stretched and weakened abdominal and core muscles that might have led to back pain, made it difficult to maintain posture, etc. As well as vanity, of course.

  • Guesty

    I had a vaginal birth of an 8lb 8 baby, they had to perform an episiotomy to get him out (and were preparing forceps, fortunately, I pushed him out first). It took me almost 6 months to fully recover and about three years to be able to run and do impact exercise without a diaper in my pants. Cue second pregnancy. I became basically incontinent during my last three months of pregnancy. As they projected another large baby, I asked my OB whether I would have a bladder after the birth. He basically said that I’d likely need to have surgery to fix my pelvic floor and supported my decision to have a C-section. It was fantastic (and glad I did it as this was a 9 lb 6 oz baby!), I was fully recovered in 8 weeks. I am back to where I was before his birth, but not to where I was before my vaginal birth. Wish I’d had a C-section with the first one as well.

    • Daleth

      And this is exactly why I despise people who say c-sections should only be available when “medically necessary” (breech baby, etc.). It’s YOUR BODY, so it should be YOUR RIGHT to choose how to give birth. If you want a c-section for your six-pound head-down singleton, that’s no one’s business but your own.

  • Amy M

    My mom had the incontinence issue pop up around perimenopause, and had a ovariohysterectomy and a bladder sling placed. She’s been fine since. I imagine a similar fate awaits me, as even now, almost 7yrs after a vaginal birth with a vacuum assist, sometimes I have to cross my legs when I cough or sneeze. I know I am not alone, I’ve had this discussion with some friends who are also mothers and many of them report similar situations.

    • Mer

      I’ve had stress incontinence since the birth of my first child at 20. It hasn’t gotten any worse surprisingly with subsequent children but it’s not gonna be fun when I get to the point of menopause.

  • Elisa

    I think it it somewhat dishonest to talk about stress incontinence and pelvic floor injury without any number of women who have only had c-sections that also have stress incontinence. I can only speak from my own experience and what I know about friends and loved ones, but I have had two c-sections without going into labor and also suffer from incontinence. My MIL had a c-section and has incontinence. My mother had three vaginal deliveries and one c-section and has no incontinence issues. If you have a c-section thinking it will prevent incontinence, you may be disappointed. I’m not arguing about the extent of damage to the pelvic floor from extended pushing or huge babies coming out of one’s vagina, but from the reading of this article, one might conclude that a scheduled c-section would prevent incontinence, and it most certainly does not.

    • moto_librarian

      Urinary stress incontinence is one thing, fecal incontinence is another. I don’t know anyone who had a c-section who is dealing with the latter. I gave birth to two small babies (6 lbs., 4 oz., and 6 lbs., 15 oz.) and continue to have issues with my bowels despite physiotherapy. I had at least heard that women who had babies sometimes peed when they sneezed. Imagine my horror to learn that you could also have that happen with fecal material.

      • Karen in SC

        moto have you looked into the Interstim device? There’s a blog by a women with fecal incontinence who has had success with it. She is an “ambassador”. Her blog is http://peaceoutofpieces.com/2014/11/13/a-bionic-pioneer/

        • moto_librarian

          Fortunately, it doesn’t happen to me very often. I do fear that as I get older, that the incidences will increase. If they do, I will definitely look into interstim. Thanks for sharing this information, Karen.

    • Gatita

      Now you’ve got me wondering how common it is for women who’ve had CS to prolapse.

      • Megan
        • Gatita

          Interesting but the data is from the 90s in Norway. I wonder what it would be today in the U.S. Still, CS seems to reduce (not eliminate) your risk.

          • Megan

            I imagine the incidence is higher all around (higher BMI, etc) but probably still somewhat lower with CS vs VB. Sorry, That was just the first study that came up. I didn’t look very hard. 🙂

          • Gatita

            Ha, no worries! I should look it up but it’s Friday and I’m tired.

          • attitude devant

            You can’t just look at c/s vs vag birth. For c/s to be protective, it has to be done before the baby has descended far into the pelvis and torn up the levator. So to get a clear picture you have to look at c/s before significant labor

      • Daleth

        Every study I’ve seen shows very different outcomes for c-sections done before labor or in early labor, vs. c-sections done after you’ve hit the second stage. Spending hours in the second stage before you get a c-section is going to damage your pelvic floor a lot more than pregnancy followed by a pre-labor or early labor c-section is.

        Some studies just look at c-sections without dividing them into separate groups based on when the c-section was done, and those studies will not give you an accurate picture.

    • Amy Tuteur, MD

      Pregnancy itself increases the risk of incontinence. Vaginal birth increases it more. Forceps delivery has the highest incidence.

      • Monkey Professor for a Head

        I wonder if the high rate of pelvic floor injuries in forceps deliveries is due to the forceps, or because forceps are only used in deliveries that were complicated to begin with. Of course it may be a combination of both.

    • FEDUP MD

      Well obviously. My mother had a c-section with me and no vaginal births and has had stress incontinence ever since and now some prolapse after menopause. I developed stress incontinence at about 12 weeks into my first pregnancy and by the end of my pregnancies have been leaking urine so constantly I was in diapers. I still get stress incontinence at times and I have had 2 c-sections and no vaginal deliveries. Mine is not too bad- as long as I do not have a full bladder I am fine! And it almost always is just sneezing (coughing, running, trampolines are all fine). I think we just have bad genes (my maternal grandmother also had bad incontinence as well). I suspect if I had had a vaginal delivery, God forbid a tear, I might still be in diapers. I have a friend in her 30s who is in diapers after a nearly 4th degree tear. She had an elective csection with her last to minimize further damage.

  • Trixie

    We will see what happens to me in menopause — but I had the opposite experience. Quite painful intercourse for a long time after cesarean, but great function after vaginal birth. No incontinence either time.
    This was luck of the draw for me, of course, and I sympathize with anyone suffering from injury after vaginal birth.

    • SarahSD

      Intercourse also improved for me after vaginal birth. But I have had occasional stress incontinence, and so not super optimistic about what might happen after hypothetical #2.

    • Trixie

      And I’ve never done kegels, either.

      • Roadstergal

        They can be fun. 🙂 Did you get PT after the C/S? TMI, but personally, my abdominal muscles are really involved in sex, particularly orgasm…

        • Megan

          Maybe that’s my issue. I have a huge diastasis too so it would make sense. Perhaps after this baby I will request PT.

          • nomofear

            YouTube/Google the Sahrmann abdominal exercises.

          • Megan

            I will! Thanks!

        • Trixie

          It had nothing to do with orgasm; it was a sharp, stabbing pain as if my incision were being torn from the inside.

    • Megan

      I’m glad you bring that up because the quality of my orgasms totally changed (not horrible but not as good as before) after my Csection. Sex was only painful until I stopped breastfeeding. I ended up pregnant again soon after so I’m not sure if it would’ve improved over time back to baseline. I was wondering if I was the only one whose CS affected their sex life. It’s nice to know I’m not the only one.

      • Kelly

        I have heard that you breastfeeding can make you dryer and lead to painful sex. After you stop, it normally resolves.

        • Megan

          Yeah I knew that going in. But I didn’t expect the orgasms to change. Maybe I’m just weird. Though I know they did have to make my hysterotomy incision very wide to get my daughter out. Maybe that has something to do with that particular change?

          • Kelly

            I wonder if it also has to do with the pressure of the baby in the last trimester. This last pregnancy showed me how messed up it can make my body.

        • Trixie

          Since I BF both times, that didn’t seem to be the deciding factor as much as mode of birth. Vaginal birth has permanently improved things for me.

      • Minnie

        It affected mine. I had to have a C-section since I was not dilating at all. I didn’t want to have one since I have a super strong core (I dance: belly dancing and dancehall) and was afraid of how it would affect my core muscles (but I wasn’t steeped in woo and thinking it was the worst thing ever and am happy with how it went, experiencing no trauma from the experience). I recovered very quickly from my C-Section, but 10 months later I’m still recovering my core strength and that seems to be connected with sexual pleasure for me. Initially, it was fine when I was cleared for sex, but when I started moving more I realize how much I used those muscles for everything so it was an adjustment for me.

        I don’t know if it is the same for other women, but that is why the lack of discussion about how it affects women’s bodies and sexual pleasure bothers me. The discussion on sexual pleasure is centered on male pleasure only it doesn’t really allow much room to have this type of discourse more places.

        • nomofear

          If you haven’t, try the Sahrmann abdominal exercises. Those fixed me up right!

          • Minnie

            I’ve been reading up on these! I do work out with a personal trainer & it took a lot of hardcore abdominal workouts for me to not feel numb there & engage that area, but I saw something on this and was going to look into it. Good to hear!

      • Amy M

        Not a doctor, but my understanding is that estrogen levels are lower during breastfeeding, and that can lead to vaginal dryness (and pain). Maybe it can also interfere with climaxing?

        • Megan

          But even after I weaned it Didn’t improve, not even now during pregnancy. I agree with Roadstergal below that perhaps it is my weakened core.

          • Amy M

            Could be. FWIW, I found that sex felt different after I gave birth….certain positions that used to be fine became very uncomfortable. It’s not a big deal to me, because my husband and I can work around that, but I can see how it might really bother someone else.

          • SporkParade

            Not to be TMI, but that happened to me AND I had an episiotomy scar that didn’t appreciate being bumped into.

    • Blue Chocobo

      Sometimes, the right new injury is the “cure” for an old one. There are ways an anterior prolapse can sit that actually “masks” stress incontinence because of how it makes the bladder relate to the urethra, etc. The downside is having trouble completely emptying the bladder, so you always feel pressure like you will have to pee soon. It can shift about with age, too, with mixed results (just like the rest of the body).

      This is per my OB a year after the last baby, as I was surprised by my ability to bounce confidently on a trampoline (couldn’t do that before that pregnancy) while other times feeling like my uterus could fall out my butt (that’s how it feels, but not, upon her inspection, at all what is happening) and needing to pee in stages.

      • Trixie

        I don’t think I have any of those symptoms, either.

  • SarahSD

    The rhetoric around MRCS among “the vaginal is best” crowd says that women are choosing this option because they are under the thrall of the patriarchy which tells them they need to keep their vaginas tight to please their man. I have literally heard this garbage in a scholarly presentation bemoaning the high c-section rate. It is so misleading and disingenuous. I mean, if a looser/bigger vagina is the worst thing that happens to you as a result of your vaginal birth, you’re doing pretty damn well. Also, what’s wrong or unfeminist about considering sexual function and pleasure, even that of your partner? The fact that they have to contort themselves into knots to make themselves appear feminist is so revealing. Any feminism that tries to police women’s choice is fake feminism.

    • KeeperOfTheBooks

      Right. Since when is it unfeminist to enjoy sex, or to want to enjoy sex?! Am I missing something here…?

      • SarahSD

        Or (gasp) to give a damn if your partner enjoys sex with you?

        I’m pretty sure it’s more fun if both people are enjoying themselves. This is not to say that having a tight vag is the end-all and be-all. But whether or not you think it’s important for your sex life is not my business

    • Sarah

      We’ve had that on here before. The only reason a woman might not want a loose vagina is patriarchy, and the only person who might benefit from her not having one is the man she sleeps with.

      • SarahSD

        Exactly –
        “the only person who might benefit from her not having one is the man she sleeps with”

        That THIS, this sexist crap gets passed off for feminism is bazonkers. And then, the brilliant hat trick that deflects it onto the woman, that it’s her fault for buying into the patriarchy. When THEY were the ones who implied that it was about male pleasure and nothing else!

        • The Bofa on the Sofa

          I always figure, what would happen if you turned it around? A guy, for example, is considered wonderful if he puts her satisfaction above his own. But if a woman does that, she is just a pawn of the patriarchy.

          • Fallow

            You know very well that the context there is tremendously different. There are thousands of years of social and historical context, demonstrating why those issues aren’t really equivalent. There is also huge social pressure for women to be pleasing to men. So as a rule, it’s difficult to extricate whether the average woman can freely and willingly “choose” a man’s pleasure over her own.

            However, women are absolutely allowed to want to preserve the sexual function of their vaginas, for whatever reason. I can’t believe anyone would argue that’s misogyny.

            I am a feminist with a gigantic, bright neon capital F, and I damned well know miosgyny when I see it. People are not victims of the “patriarchy” just for wanting their organs to function properly. To say otherwise is insane.

          • fiftyfifty1

            A man is considered wonderful if he puts her satisfaction above his own in just the same way that fathers are praised for babysitting their own kids. Involved fathers sometimes get offended when people (even often women) praise them for that, but really it makes sense. Men, until the last 2 generations have never been expected to do so much as lift a finger with their kids. And men who are as involved with their kids as their wives are are still rare. And men may choose to care about their partner’s pleasure, but throughout human history pleasing their male partners has been a life or death matter for women. So many cultures have a 1001 Arabian Nights/ Book of Esther type story.

    • LizzieSt

      Long ago, I read a radical feminist text that made some rather disturbing claims about cesareans. Apparently, OBs, all of whom are evil patriarchal males, of course – don’t like vaginal deliveries because they prefer to “save the vagina, the birth canal of old, for the husband.” Instead they prefer c-sections because then they can…………uh, is there any way to put this delicately?……..penetrate the uterus themselves, directly, with a knife. *ahem ahem*. Truly, I am not making this up.

      I kind of wish I could remember who wrote this. On the other hand I don’t want to know. I am absolutely a feminist, but the radical fringes of feminism can be downright scary.

      • SarahSD

        Gross.

      • SarahSD

        Andrea Dworkin.

        • LizzieSt

          That’s the one! I found the quote on Google Books. It’s Andrea Dworkin……because of course it’s Andrea Dworkin. And that passage is even worse than I remembered. Yikes.

          • Tosca

            Andrea Dworkin is well known to be lunatic fringe. She is to serious feminism, as the tin-foil hat alien abduction brigade is to NASA.

          • SporkParade

            Was she also the one who said that the way we talk about menstruation is sexist because we use negative terms like “break down” and “disintegrate” to describe what’s going one, whereas we use much more positive terms to describe erections?

          • LizzieSt

            Probably.

          • SarahSD

            I think that’s Emily Martin, an anthropologist who wrote The Woman in the Body, which is a cultural analysis of reproduction. I have not read it, and I wouldn’t be surprised if it had some problematic anti-western-medicine aspects, as a lot of anthropology does, but I engage with some of her other work in anthropology of science, and I think she’s alright. Among other things, that book looks at the language used to describe reproductive processes in males and females. Analyzing how language produces sexual difference is as old as feminism itself. Some of this argument also appears in her stand-alone essay, The Egg and the Sperm (which I have read). I think there’s something to the argument that the language used to describe phenomena shapes and limits what we are able to know about a particular phenomenon. Like recently we are starting to understand some of the things the egg does in the reproductive process (beyond “receiving” the sperm); years of stubbornly describing female reproduction in passive terms relative to the male did not help that. Or, like the decades (centuries) of dismissing and ignoring the injuries and problems discussed in this piece as “women’s problems”…

          • SporkParade

            I actually found the piece comparing the language of menstruation and erections to be dismissive of women’s problems. I’m not a fan of my menstrual period, and it’s not because the patriarchy told me not to be.

          • SarahSD

            Sure. Not sure if it’s the same piece – though it sounds like it might be. The piece I am remembering was not only about menstruation but the
            entire reproductive process, including the language describing how the
            egg travels. What I took away from it was more an argument about how language shapes what questions we ask and what we can know, less about whether that language shapes how women experience their periods. I wouldn’t be surprised if both elements were part of the argument, though.

      • toni
        • LizzieSt

          Oh, for goodness’ sake. There is nothing wrong with feminists criticizing aspects of health care. But they should now what they are talking about first, and not make sweeping claims. My mother had a hysterectomy in her early 40s because she had periodic massive hemorrhaging from fibroids, not because she had a “female predilection for self-mutilation.” (Grrrrr, that phrase makes me angry! “Feminist”, my foot!)

  • Laural

    Thank you for reflecting on this, Dr. Amy.
    I have not read all the comments so forgive me if this is a repeat, but I believe wholeheartedly that it women should be allowed to choose a C-section if they want it.
    I also believe that there is not enough awareness of this issue and it goes to informed consent.
    In training to be an obstetrician, how much emphasis is there on the preservation of pelvic function?
    I have a history of precipitous births- my third, a horrific experience, left me and my baby damaged. My baby is fine now, just took a week in the NICU. My midwife had never seen any prolapse and the look on her face at my postpartum check is something that will always remain with me. I suffer from bladder and rectal prolapse and it is extremely humiliating and a source of shame. I was 33 when it happened. I will live with the consequences the rest of my life. After menopause it will doubtless be worse. Not sharing to ‘poor me’ but to illustrate that the consequences of vaginal birth can be profoundly life changing. Things like jogging, sex, chasing and actually picking up children- or jugs of milk- things one might take for granted- can be affected. So, HUGE quality of life issues- vs. something so temporary like vaginal birth or C-section.
    I would just advocate for informed consent and freedom of choice. And hope that more research is done on interventions that can avert pelvic prolapse associated with vaginal birth.

    • Gatita

      Your story and others like it, plus my own experience of having a life-threatening complication after giving birth to my son, is what’s made me even more pro-choice than I was before I got pregnant. No woman should be forced to give up her autonomy and take on this level of risk involuntarily.

      I agree that more research is needed and I think the reason we haven’t had much is because “women’s issues” aren’t considered urgent or important. Which sucks.

  • Jenny_from_da_Bloc

    My first son’s head measured 16cm at birth. The nurse commented that it was a good thing I had a c-section because I would have been “completely and utterly destroyed.” The OB was shaking his head in agreement. I think about this every time I sneeze lol

  • Spooby

    Long time reader of Dr. Amy who wants to chime in for the first time: Thank you for this post. It’s because of the information presented in this blog that I am going to be asking my OB for an MRCS (36 yrs old, currently 5wks along with my first and probably only child). I don’t feel comfortable risking an emergency c section, operative vaginal delivery, obstetrical tears, or sexual dysfunction due to the crapshoot that is vaginal birth. If anyone has any tips on how to broach this subject with my OB so that my request appears well reasoned and rational, I’d appreciate it.

    • Daleth

      Read this book–it may be at your local library–I found it very helpful:
      http://www.amazon.com/Choosing-Cesarean-Natural-Birth-Plan/dp/1616145110

      Also, here’s a study (or rather, a summary of a study) about the risks to babies of vaginal births–maybe print it out and bring it?

      Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise
      Hankins GD, Clark SM, Munn MB.
      Semin Perinatol. 2006 Oct;30(5):276-87
      http://www.ncbi.nlm.nih.gov/pubmed/17011400

      • Spooby

        Thank you! I will definitely check it out. I go in for my first prenatal visit next week and I want to be well prepared and informed. I’m so thankful for the science based information that’s presented on this site as well as the quality of the discussion in the comments section. It’s a rare thing these days on the interwebs.

      • The Bofa on the Sofa

        Pauline Hull is awesome.

    • Jen

      Hi there,
      I had an elective C-Section to prevent urinary incontinence. I told my Gyno that I already had mild urinary stress incontinence and wanted to prevent worsening symptoms. I was referred to a urogynecologist and upon consultation he sent the recommendation to my OB that I should have a C-Section. It worked and I got the birth of my choice. I loved it. No pain. No contractions. Baby was born perfect with no issues whatsoever. I went In to the hospital at 7:30 and had a baby by 9am. I now have no exacerbated symptoms of incontinence and a perfectly healthy sex life. Go for it! C-Sections rock! Oh and my son is the light of my life and we are perfectly bonded. He’s a happy, healthy, perfect weight, adorable, no allergies/ asthma, toddler. He got lots of formula too 🙂

    • Sarah

      Congratulations.

      I’d start with your age, since the EMCS rate generally increases with over 35s. I guess you may be 37 by the time the baby arrives, so perhaps ask what the odds of uncomplicated vaginal birth are for a 37 year old first timer.

    • Blue Chocobo

      Broach the topic soon, so you have time to find a doctor that will respect your informed consent if your current doctor won’t. A lot of OB practices have websites, if they do purely elective sections they will usually have that info on the website.

    • Grace Adieu

      I said “Can I have a c-section”?”and he said “Yes”.

  • moto_librarian

    Anyone who claims that we do not live in a deeply sexist culture needs to read this. True informed consent would include information about pelvic floor problems. You can bet your ass that if men became incontinent or experienced prolapse at rates upward of 75% that something would be done about it, yet so many women suffer in silence because the problem is embarrassing. At the very least, every HCP needs to ask women about their pelvic floor health postpartum and at their annual exams. The only reason that I go therapy was because I told my CNM that I was having problems. I knew I had to do something about it, but I still hated having the conversation.

    • SarahSD

      “women’s problems”

    • Inmara

      Actually, possibility of incontinence never got mentioned during my prenatal classes, and there was like one sentence about Kegel exercises. In 6 week check-up my gynecologist didn’t say anything either, though she obviously saw that things around my vagina is not the same anymore (an I’m having stress incontinence now). It’s shocking to learn that majority of women is affected by such problems but even more shocking that it’s such a taboo topic that even health care providers doesn’t discuss it with patients.

  • Monkey Professor for a Head

    I remember when I was a med student, I met a woman who had had a colostomy because of faecal incontinence from childbirth. She considered it a great improvement.

    I’ve always thought there was something profoundly sexist about the lack of discussion about pelvic floor damage in birth. There’s an implication that vaginal birth is more important than a woman’s self esteem, and that her future enjoyment of sex is unimportant.

  • FrequentFlyer

    Has anyone else noticed how young women in incontince pad advertisements are now? It used to be much older actresses who did those commercials. NCB activists and doctors may not have noticed the growing problem, but I think someone in marketing has.

  • Dr Kitty

    This time there were free samples for incontinence pads in the Bounty pack I got in hospital.

    I was unimpressed.
    Firstly, because I think women who have incontinence shouldn’t have it normalised to the point where they don’t seek treatment, and secondly because I don’t think it should be seen as an acceptable consequence of childbirth that is a price worth paying in order to reduce CS rates.

    I always ask about continence at post natal and well woman appointments.
    I want to make it clear that there are treatments available and that no one needs to suffer due to embarrassment.

    I’m also sure that the reason I personally don’t have any issues is because I chose CS and ERCS.

    • araikwao

      Yes!! Agreed re the normalising, creating a label for it, and no mention of the effective (for the majority) treatment available.

    • Bombshellrisa

      ^^^^”I think women who have incontinence shouldn’t have it normalized to the point where they don’t seek treatment”. Yes! I can’t be the only one horrified that Poise now sells disposable pessaries that look like tampons and have three different strengths. They are available in the “feminine hygiene” aisle at the grocery store.

    • Joy

      I was asked at my 6 week check and was told to do Kegels for at least 3 months. I did find it disturbing that the 6 week check literally involved no physical checking though. I thought it would involve taking a look.

  • Anna

    How awful! It could have been me! I am not very big, had large baby (husband big), have some Asian heritage and family history of difficult birth! Nobody ever tells that! It’s always this “vaginal is better by default” rhetoric. Better for whom – that is the question.

  • Jessica

    This is a great article. As a teenager I’d hear older female co-workers joke about crossing their legs when sneezing and not having the same kind of bladder strength that they’d had before kids, but it didn’t really make sense until I was pregnant the first time and started experiencing stress incontinence with sneezing, coughing, and vomiting.

    The nurses at the hospital told me I’d had a third degree tear and I spent the first six weeks postpartum feeling incredibly damaged. (My OB was adamant that I absolutely had not had a third degree tear). The stress incontinence got better after birth, but did not disappear. I’m now 20 weeks pregnant with my second and dealing with it again. It’s not really funny. I’m not sure I would have made a different choice regarding vaginal birth vs. C-section, and I’m still planning a vaginal birth, but I am going into it with eyes wide open, and I’m irritated that so many people dismiss how this type of damage affects women for the rest of their lives.

    • Minnie

      After having a baby it amazes me how much is NOT talked about. I think because of the popularity of NCB types in discussion you see a lot about C-sections, breastfeeding and bonding, interventions, but you rarely see just general talk about the downsides that go with labor. Or how dismissive some women’s concerns are. Baby blues? Some intervention stopped you from bonding; pay no mind to how common it is. And it really upsets me when women are concerned about incontinence and vaginal muscle tone after birth to see it purely framed around a man’s sexuality vs her own well being and sexual pleasure. It’s like it is not even a possibility.

      I saw an article on Jezebel about a woman who had a vaginal rejuvenation surgery after giving birth. It was very candid, posted some BS stats on C-Sections, but I was glad to see people talking openly about it.

      • SarahSD

        What makes it even worse is the fact that NCB advocates demean requested C-sections by framing the choice in terms of male pleasure, with no attention to how vaginal birth can create a host of issues, including but not limited to the woman’s own sexual function.

      • Bombshellrisa

        NCB types rarely think past the “child bearing year”.

  • oceanlily

    My mother sustained major pelvic floor damage during my birth. It took talking to seven different OBs to find one who would agree to a C-Section so it wouldn’t happen to me. Then my daughter decided to just slide right out in our bathroom after I had almost no contractions until she was actually about to come out with no time to even call 911. Wish I’d known she was planning this, it would have saved all the phone calls and clucked tongues and the judgemental women. And thus far I have had no issues after the first six months PP.

  • I sometimes wonder if it was some kind of cosmic plan – to instill a kind of empathy between mothers and their potty training toddlers….

  • critter8875

    I’ve always thought that if I did give birth I would opt for c-section and epidural (if not total) anesthesia.

  • attitude devant

    A minor complaint: I hate the photo. She’s obviously been photoshopped to have a narrower waist. Pointless on this otherwise always excellent page. I know you don’t make the photos and the wet jeans convey the idea needed.

    OK. Carry on.

    • AirPlant

      The picture is probably photoshopped because DUH, but that is not an impossible waistline for her body type. I am a big hipped lady and my silhouette is just like hers minus the thigh gap. I have skinny friends who look just like that. On a personal note, I have spent most of my life with my hips being out of vogue and I am kind of loving this new thing where curvecious is portrayed as attractive, not just giant boobs on skinny women.

    • oceanlily

      That is exactly what my body looks like: thin waist, big hips and a thigh gap. While it might be photoshopped, I certainly am not. That could easily be a real person.

    • toni

      looks completely normal to me

    • Who?

      Pretty much my shape.

    • attitude devant

      LOL! cf, below, I am delighted we have so many Barbies commenting here. I see at least 20 naked women every work day, many of them professional athletes, and, trust me, that is an unusually narrow waist. I have big hips and a sizeable bust too, and even at my most fit (BMI 17) my waist was never that narrow. But as I said, carry on.

      • toni

        Might be unusual but that doesn’t make it hate worthy. Are we even looking at the same picture lol… It’s not an athletic body type (I don’t see any ab definition) it’s just a curvy figure and not even an extreme one imo. Most Americans are overweight and I think that skews a lot of people’s perception of normal. I’m really surprised you think that’s Barbie-esque

      • Dinolindor

        Just curious – have you compared the image between how it appears on the home page slide show and on the post’s page? Because I see significant distortion of the image on the homepage where the shape looks pretty unnatural, just as you describe it. But then the shape looks more natural on the actual post.

        • attitude devant

          Yes, I do see that, but even on the actual post it looks photoshopped. I suppose it could possibly be a browser issue, or have to do with my screen ratios…..or something.

  • demodocus

    Mine’s only the mild sneeze-blow nose-cough kind, but it’d be rather nice if even that didn’t happen. 🙁 And the 18month long temporary problem of never being able to trust a fart. Now when my father whines about being old and having these problems, I roll my eyes.

    • Squillo

      Bad news. My last vaginal birth was 9 years ago, and I still can’t control my farts. And let’s not even talk about the queef-fest that yoga still is, despite Kegel-ing my little heart out. I also have a vaginal vault prolapse and a rectocele (neither of which is hugely problematic at the moment, but may be later.)

      I was aware of the possibility of stress incontinence, but no one ever told me about the rest of it.

      • demodocus

        That sucks.
        It’s been 5 or 6 months since I had to worry about brown streaks in my underpants, thank goodness. ‘Course, now I’m expecting again, so who knows.

        • Blue Chocobo

          Sorry about the bladder, but congrats on the new uterine tenant!

        • Squillo

          YMMV–my kids were big, and # 1 got stuck after 4 1/2 hours of pushing, so…

      • moto_librarian

        Yup. So sorry that you’re part of this club. I am always terrified that I will have uncontrollable gas whenever I am teaching. It sucks.

        • Squillo

          Thanks. It’s not that horrible actually. I’m careful about not eating food that is likely to give me gas, and mostly it’s when I get up from lying down that it’s a problem. And I gave up public yoga… It also helps that, as I get older, I’m less and less embarrassed by these things.

  • attitude devant

    There was a professor at University of Colorado, Denver who studied the lifelong cost of birth alternatives in the 1980s. He always said that if we were making decisions based on cost alone that c/s was clearly the cheaper option, since by performing c/s we could avoid all the surgical costs and personal costs of pelvic floor damage.

    I think this would be even more true today, since our population is living so much longer, and we know that the typical repair lasts only 10 years or so, with outcomes being less and less benign with each trip to the OR.

    When I look at my patient population and see the number of women who can’t run, or lift weights, or have comfortable intercourse, or be far from a bathroom (and keep in mind I share some of these problems), I marvel at the women in the NCB world who push for vaginal birth at any price. Let me tell you: the price is very high indeed.

    • And given the choice between surgery in my thirties, when I am in my best physical form, or in my 50’s, I’d choose my thirties.

    • Daleth

      He always said that if we were making decisions based on cost alone that c/s was clearly the cheaper option, since by performing c/s we could avoid all the surgical costs and personal costs of pelvic floor damage.

      It would also avoid the cost of all the birth injuries caused by vaginal birth, ranging from relatively cheap temporary injuries (broken arms or clavicles caused by freeing a baby from shoulder dystocia) to permanent brain and/or nerve damage caused by oxygen deprivation. Here’s a study that tries to quantify that:

      Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise
      Hankins GD, Clark SM, Munn MB.
      Semin Perinatol. 2006 Oct;30(5):276-87.
      http://www.ncbi.nlm.nih.gov/pubmed/17011400

      • The Bofa on the Sofa

        I do object to their misuse of significant figures.

        Going from “3 million” to 11400 bad enough, but then to subtract 1962 and claim that 9438 cases could be prevented is complete lunacy.

        You can’t take an estimate of 3 million births and get something precise to the single digits. It’s 9000. Maybe 9400 if you want to push it.

  • LizzieSt

    This is a great thing to keep in mind when certain persons (Why yes, Alice Dreger, I am talking about you!) insist that vaginal birth is always superior because it’s so “sexy.”

    I am referring to this bit of nonsense, from a bioethicist who really should have known better, and yes, she actually said “sexy”: http://www.theatlantic.com/health/archive/2012/03/the-most-scientific-birth-is-often-the-least-technological-birth/254420/

    Dr. Amy wrote about her here: http://www.skepticalob.com/2012/03/another-day-same-old-natural-childbirth.html

    There is nothing sexy about incontinence. It’s the complete opposite of sexy. The aesthetic negative space of sexy.

    (I brought this up because I just found that article by Dreger, and it really ticked me off because I have otherwise admired her work)

    • demodocus

      unless your spouse is a copraphiliac, maybe

      • LizzieSt

        True, there are always exceptions.

    • Anna

      I have always suspected this whole “vaginal birth at all costs” thing was more about self-esteem than safety or bonding with the baby. It’s all just for the sake of being able to say later on: oh, you know, I’m more of a woman than you because I actually GAVE birth to my baby.

  • And the women who know, who request caesareans – often find themselves struggling to find a care provider and a hospital that put the patients’ right to choose caesarean ahead of policies to reduce the rate of caesareans. How many women are subjected, sometimes against their well articulated wills, to vaginal deliveries in order to keep the caesarean rate low? They are the victims of the mantra that caesareans should be reserved for cases where “medically necessary”.

    • Daleth

      Yes. That was my experience–I had to push like hell to get a c-section without first trying to induce labor, even though I was carrying mono-di twins. It was INSANE.

      • Amy M

        Are you in Canada?

        • Daleth

          No, I’m in the US! So if I had as much trouble as I did, with doctors in a litigation-happy country (and my docs knew I am a lawyer!), I can only imagine how hard it would be to get a MRCS in Canada.

          Opposition to MRCS is fundamentally antifeminist. It is NO ONE ELSE’S BUSINESS which way a woman gives birth. CS is actually safer for the baby than VB (I mean it eliminates all the risks of vaginal birth and adds no significant risks to the baby of its own), which makes it all the more obnoxious for people to oppose it.

    • Inmara

      In Latvia, it’s easy – you can have MRCS if you can pay for it. Meaning, if you have around 1500-2500 EUR in your pocket which is unreal for majority of families given that median salary in country is 500 EUR (and most insurance policies doesn’t cover anything birth-related because these services are supposed to be free).
      Medically necessary C-sections are covered by government and there are many cases when women have to fight to get recommendations to have C-section approved in hospital if they come from other health care providers or gynecologists outside of hospital (there is not only pressure to reduce C-section rates because of “natural birth is superior” but also insufficient funding from government to perform as much C-sections as there actually are).

  • LovleAnjel

    I had an emergency C-section, DD’s was stuck during pushing (an anterior lip developed). I thought I was okay, pelvic floor wise. I got more crotch wetness when I work out or go for walks, but I had thought I was just a bit more sweaty than I used to be. Finally, two years later, I realize that was not sweat. I uncontrollably pee when I do anything active. I did no think I would be buying continence pads in my thirties.

  • Daleth

    This is a hugely important discussion. I chose a c-section myself, and when my doctor went through the rigmarole of warning me of all the risks of c-section, I asked him, “Do you warn women about the risks of vaginal birth, too?”
    “Actually no,” he said, in a tone of voice that suggested he thought that wasn’t a bad idea.
    Personally I think doctors (and midwives, and Certified Pretend Midwives) should be legally obligated to warn patients of the risks of both ways of giving birth. If you don’t know about BOTH sets of risks, you’re not making an informed decision–so there is no informed consent.

    Little typo: I think you meant continence, not incontinence, in the following sentence: “a 3rd degree tear.. makes incontinence of flatus (gas) and stool, impossible.”

    • Amy Tuteur, MD

      Thanks!

  • Mel

    Thanks for posting this.

    My mom is schedule to undergo her second set of surgeries for pelvic floor repairs. The delivery that probably caused it was something out of the NCB playbook: Mom had a long back-labor with my brother David. She was pushing for several hours with him still in OP position. He was eventually born vaginally, but it caused her urinary incontence starting soon after his birth.

    Vaginal birth isn’t a panacea.

    • Roadstergal

      “Vaginal birth isn’t a panacea.”

      How did we ever get to the point where we thought it was?

      I’ve mentioned it before, but I was very young when I first heard about C-sections, and it sounded like the most wonderful thing ever. Having a baby without trying to jam something that big through an opening so small?

      I know it works well for a lot of women, but it just seems odd to me for it to be taken as an Unalloyed Wonderful Thing overall.

      • Squillo

        Yup. Vaginal birth is one good way to have a baby. C/S is another. They both have risks and benefits, and women should be informed of both and allowed to choose the risks she prefers.

        • fiftyfifty1

          “Vaginal birth is one good way to have a baby. C/S is another. ”

          Naw. More like this:
          Vaginal birth is one bad way to have a baby. C/S is another bad way.