Damage during birth

At first, I scoffed at the idea. Who had time for physio appointments with a newborn, and how would I exercise those mysterious, invisible muscles anyway? Then my doctor told me, “If you ignore the problem, it could lead to incontinence.” That got my attention.

Like me, about 10 per cent of women who give birth vaginally each year experience an injury during labour and delivery that can potentially result in pelvic-floor disorders. These include urinary and fecal incontinence, and pelvic-organ prolapse, when the uterus or bladder drops into the vagina.

Though experts aren’t sure what causes pelvic-floor disorders, giving birth vaginally is linked to far more problems than having a Caesarean section. The use of forceps during the vaginal delivery compounds the risk. In fact, according to the director of the US-based Pelvic Floor Research Group and professor of gynaecology Dr John DeLancey, “What’s most associated with muscle damage is a forceps delivery.”

The sad news is that no-one can reliably predict what will actually happen to your vagina during a natural birth. You may be one of the lucky ones who has a four or five-hour labour followed by a short and relatively pain-free delivery with no muscle damage or tearing.

On the other hand – and there’s no gentle way to tell you this – you may tear, bruise, need an episiotomy (when the perineum is cut to let the baby’s head through) or get what are commonly referred to as skid marks, a kind of graze on the inside or outside of your vagina.

What is a fact is that injuries happen more frequently during a woman’s first delivery, although problems can arise as a result of subsequent births. The risk of developing urinary incontinence rises only slightly if you have given birth more than once.

Unfortunately, studies show that having several children boosts your odds of developing the more serious problem of prolapse. Delivering one baby vaginally makes you four times more likely to have pelvic-organ prolapse. Having two vaginal births bumps your odds up eight times. Bearing three babies vaginally jumps your chances up 10 times.
Some women blame pelvic-floor problems on having a vaginal birth after a Caesarean (VBAC), but studies do not support this theory.

“A VBAC is like any other vaginal delivery,” explains Dr Mark Walters, the chairman of the American College of Obstetrics and Gynaecology Committee on Urogynaecology, adding that the reason a woman may have had to have a Caesarean could be the cause of the problem when she delivers vaginally later.

For example, a woman with a tight or narrow pelvis would avoid trouble during delivery by undergoing a Caesarean. However, if she has a subsequent vaginal delivery, she might then have a problem. So any damage that occurs is not the “fault” of the VBAC itself but the result of delivering vaginally given her anatomy.

Preventing the problem

There is controversy over electing a Caesarean delivery solely to avoid pelvic-floor disorders. “I am very much against everyone having C-sections,” says Dr DeLancey, who points out that if every woman had a Caesarean delivery, for every 10 Caesareans performed only one case of pelvic-floor injury would be prevented.

Dr Walters says women who have a high risk of pelvic-floor damage – either because they have a tight pelvis, a maternal family history of prolapse or incontinence or their babies are really big – might want to consider an elective Caesarean.

Indeed, because of her mother’s and grandmother’s history of urinary incontinence 26-year-old Capetonian Natheema* decided to elect a Caesarean rather than a vaginal birth. “My grandmother had five babies naturally and suffers from urinary incontinence. You hear all sorts of stories about tearing and other problems and vaginal preservation became my number one priority. The pain from the Caesar surgery didn’t worry me. My husband would have supported me either way but I didn’t want anything to be wrong down there and he says nothing has changed.”

Natheema is not alone. When Fit Pregnancy asked women who had elected to have Caesareans what their motivation was, many were prepared to admit (without being quoted) that they were very frightened of tearing and didn’t want their sex lives affected by damage to their vagina.

But, despite scare stories, it’s really important to remember that in the vast majority of cases, the vagina returns to normal within weeks, sometimes months (depending on the nature of the birth). After most births, it is recommended to wait for six weeks before resuming your sex life and to go gently when you do. Intercourse may be a little uncomfortable due to tenderness, tightness, hormones (which can inhibit lubrication) and anxiety.

But you must remember that the vagina was designed for birthing, as well as sex, which is why it is so flexible. Stories of women with gaping, stretched-out vaginas are simply that – stories fuelled by fear and the ongoing, heated debate around natural birth versus Caesarean.
It’s important to remember that even elective Caesareans, which are safer and easier to recover from than emergency ones, come with their share of unpleasant (and potentially dangerous) risks and side-effects.

So, as far as studies available, here's the deal: there is a slight increased risk of temporary pelvic floor damage (most often in the form of urinary incontinence) from a vaginal birth. This means a squirt of pee when you sneeze or cough now and again for about the first year or so. Long-term effects are rare. Many women have stress incontinence later in life but gravity, genetic disposition, age and other health issues are considered the main causes.

Should you rather have a Caesarean?
Dr Walters agrees with Dr DeLancey that too many C-sections would be required to make a difference to the total maternal population. And a C-section – major abdominal surgery – carries its own risk. So what can you do to reduce the risk of pelvic-floor trauma?

Doing Kegel exercises (when you contract and relax the muscles surrounding the vagina, as if you’re trying to stop the flow of urine) “can’t hurt and might help,” says Dr DeLancey, who adds that Kegels help speed healing of the pelvic-floor muscles after delivery.

“I’m a strong advocate of pelvic-muscle training, but I’m not saying those exercises will prevent injuries,” he says.
It’s not simply a vaginal birth that can cause damage that leads to incontinence. Age, smoking and being overweight are major contributory factors. Being at a healthy weight and quitting smoking before getting pregnant might reduce a woman’s risk, says Dr Rene Genadry, co-author of A Woman’s Guide to Urinary Incontinence (Johns Hopkins University Press).

Fixing any damage

If you suspect a problem after having a baby, discuss it with your gynaecologist within the first couple of months. Your doctor may refer you to a specially trained physiotherapist, as mine did. Most physiotherapists use biofeedback, positioning either an internal probe or electrodes on the perineum – the area between the vagina and anus – to provide visual awareness on a computer screen of your pelvic muscles working. Because you cannot see the muscles contract and because they do not contract into or against anything, they are harder to isolate than other muscles in the body.

If physical therapy doesn’t work, surgery to attach a small “sling” to the pelvic muscles can be performed; this takes 20 to 30 minutes and requires only light sedation and a local anaesthetic. Prolapse surgery takes one to two hours and requires a general anaesthetic. However, before considering surgery, doctors suggest waiting until after your baby’s first birthday to see how much healing occurs naturally. Success rates are good – there’s an 80 to 85 per cent chance of eliminating “leaking” when you sneeze.

As for me, hearing my doctor say the word “incontinence” was motivation enough to seek help right away. I started working with a physiotherapist the following week, and I'm proud to say I’m leak-free, even when I run. And as a marathoner, that’s saying a lot.


5 signs of trouble
Signs of a pelvic-floor disorder range from slight to severe. Here are symptoms to look for up to 12 months postpartum.

1) Urine leakage when you sneeze, laugh, cough or exercise.
2) Difficulty pushing out a bowel movement or feeling pressure on your perineum when bearing down.
3) Trouble keeping a tampon in.
4) A feeling of looseness in your vagina during intercourse.
5) The sensation that something is dropping down in your vagina during activities or intercourse, especially when you are on top.