It’s time to face something unpleasant

I have the day off before a night shift so after dropping my baby at daycare, I went for a run this morning.  And that’s when I finally had to admit something to myself.

I have stress urinary incontinence.

It’s not bad.  I can run and have been running since 4-5 weeks postpartum without any “accidents.”  I just don’t usually run right after drinking a cup coffee, okay, two cups of coffee.  This morning I was running with a full bladder and also with a bladder that was somewhat irritated from whatever it is in coffee that irritates your bladder.  The entire run, I felt insecure.  I felt that if I relaxed my vigilance for a moment, I would have urine running down my legs.  Since I normally don’t have this problem when running, I would say my stress incontinence is mild and, for the moment, controllable with behaviour modification – like not running right after drinking two cups of coffee.

I’m about nine months postpartum.  I know that if I complain, I am likely to be told that I should have patience.  That things will get better.  That those bits down there are still “healing,” and that the muscles that make up my pelvic floor are still in the process of returning to their pre-stretched-during-pregnancy shape and still becoming stronger.  I am likely to be told to keep doing kegels and not to worry about this.

Bollocks I say.

I am worried about this.  I am worried about this because I know that the damage is already done.  Sure, it might continue to get better…but only temporarily.  If I have another child, it will get worse during pregnancy.  If I have another vaginal birth, more damage will likely be done to my pelvic floor.  As I age and my tissues atrophy and become less elastic, my stress urinary continence will only get worse.  Probably it will get bad enough that behaviour modification will no longer be sufficient and I may have to decide to have an operation to suspend the neck of my bladder.  I know what that entails first hand because both my mother and my grandmother have been down that road.  Both, by the way, have had complications from that procedure that have left them with continued pelvic floor disabilities.

I know why I have this condition.  I had a vaginal birth.  Further, that vaginal birth was complicated by a second degree tear.  Sure, I was repaired…but that tear went through the muscles of my pelvic floor, a fact that was brought home to me during the first week whenever I tried to engage my core, for example, by rolling over in bed.  My pelvic floor will never be quite the same as it was before it was ripped apart and stitched back together.  I provided anesthesia for a list of patients this week that were having hernias that had formed at the site of prior abdominal incisions repaired.  These hernias had occurred years after the surgical site had healed as the aging tissues of the abdominal wall slowly lost their elasticity and strength.  The same thing is going to happen to my perineum.

I’m not angry about my birth experience.  At the time that my son was yanked out of me his was having repeated late decelerations.  He needed to come out right then if we were going to avoid brain damage or potentially death.  At the time I would have agreed to anything that would have helped him including being ripped apart with forceps or a C-section with inadequate anesthesia.   It didn’t dawn on me to think of the consequences to myself.

But with hindsight, I wish I’d thought about things more critically prior to labour commencing.  When I got pregnant, I thought it was an a priori conclusion that a vaginal birth was better.  That is what is pushed at women from their providers, from the health ministry, from the WHO, from other women…its what I was told in medical school and I simply didn’t take the time to figure our what exactly was “better,” what the evidence said or what exactly the magnitude of the risks really were.  I might have still chosen a trial of labour but the important thing is that I would have done so eyes wide open, knowning the magnitude of both the risks and the benefits.

If I had the ability to see into the future and know that I would come away from my vaginal birth with pelvic floor damage that is likely going to curtail my activities and lifestyle in the future and may require a future operation, I would have chosen an elective c-section at term.  What about the pain and the recovery you say?  Well, a second degree tear is a tear through the skin and muscle of the pelvic floor.  How is that manifestly different from an incision through the skin and muscle of the abdominal wall?  Both hurt when you cough, pee, poo, roll over in bed or activate your core to lift your baby.  At least with a c-section someone offers you stronger meds than tylenol and advil.  In fact, if I could go back, I would have asked for some stronger painkillers.  I wouldn’t have assumed that because I’d had a vaginal birth I didn’t need them.

So how does my SUI make me feel?  Hurt?  Angry?  Ashamed?  No.

I feel motivated.

I feel motivated to try to repair as much damage as I can and I feel motivated to protect my pelvic floor from further injury.

If I have a daughter, I feel motivated to tell her the truth about vaginal birth so she can make an informed decision based on her own preferences and risk tolerance.

I feel motivated to speak out to health policy makers to make sure that elective caesareans at term are a choice women are allowed to make in the absence of a “medical” indication.

When I next see my family physician, I will be asking for a referral to pelvic floor physiotherapy.

If I am lucky enough to be pregnant again (and as I get older and older and older I’m not willing to take that as a given), I will be asking my OB about strategies to protect my pelvic floor during the birth.  Is the damage already done or will more damage occur during a second vaginal birth?  What are the odds of getting another second or higher degree tear?  Given that my first vaginal birth didn’t take that long (6 hours) and my mother has a history of precipitous birth, what is the likelihood that my second birth will be precipitous and what implications does that have for my pelvic floor?  What degree of harm reduction can I expect from chosing a caesarean birth this time around?

Links:

http://birthtraumacanada.org/index.html

http://peaceoutofpieces.com/

 

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27 comments

  1. Rebecca · · Reply

    I feel for you. While my pelvic floor is intact (thanks to the fibroids that forced my son into a transverse lie), I went through a year of unpredictable urinary events (thanks to the softball size fibroid that ate my right ovary). Losing the ability to control our basic bodily functions can be so incredibly humiliating.

    Anyway, thank you for this empowering piece. Sometimes the educated choice really is a c-section.

  2. This really strikes a cord with me – what if you went into it “eyes wide open” – what if you had chosen that elective c-section, and what if it was then with held from you? I too experience some stress urinary incontinance – it wasn’t very fun, particularly during that first trimester when rarely could I puke without also then needing to change my pants. Stong bouts of coughing also result in some leakage – and never should I do dishes with a full bladder…

    Eyes wide open is good/great – but if choice isn’t protected, does it matter?

  3. I’m so glad that motivated is what you feel in regards to the incontinence piece. It takes a brave and compassionate person to talk so honestly and openly about their own struggles with something so personal. I commend you for helping others with your story. I loved the part where you write about recovery from a vaginal tear vs. a c-section. I feel the same way when people bring up the idea that a tear in the vaginal area is somehow extremely less painful. I would have LOVED a higher level of painkillers and higher level of compassionate understanding that often comes from the medical field and society when recovering from a c-section. Instead, I had a busted up vagina, a few advil, and a leaky rectum. Thanks for providing a link to my blog, I appreciate it. Keep pushing for good physical care and best of luck! -Lauren

    1. Lauren, I think your writing is beautiful and your story is important. I don’t think it’s that’s brave to talk about a little stress urinary incontinence – it is so incredibly common, but how you share your story really is brave.

      I don’t understand why stronger pain relief for perineal tears is not offered. You would have access to better pain control if you came in for surgery on that area as an outpatient. Do maternity care providers think that a newborn baby is somehow analgesic and rubs numbing goodness all over the vagina on his or her way out? At the time, I was so distracted with just trying to cope with everything that I didn’t seize the opportunity to provide feedback about my pain control to my OB. I wish I had.

  4. What do you think of Katy Bowman’s ideas about squatting?

    1. I had never heard of Katy Bowman before. Since you brought her up I’ve spend some time on her website. I am a non exercise physiologist/ kinesiology grad and have to rely on my own (semi-distant) anatomy training so take this with a grain of salt, but I think there is probably something to what she says. The pelvic floor is connected to the bony pelvis as are some of the female internal organs. Squatting is a great exercise and, provided you have health knees and good technique, is not likely to lead to harm. We did tons of squats in my prenatal fitness class and the instructor was very clear about how beneficial they could be for labour and delivery and pelvic floor health so either this idea is not exclusive to KB or it’s been disseminated out to fitness professionals.

      Strengthening exercises for the pelvic floor are beneficial when it comes to incontinence…but the issue leading to incontinence is not 100% due to bony alignment. Childbirth and birth trauma damages tissues and for many women, squats are not going to fix that and the info on KB’s site seems to discount this as a mechanism. If muscles are avulsed from their bony attachements or fascia is torn and not repaired, you can squat all you want (and kegel all you want for that matter) and still not have a resolution to your problems.

      In general, when someone is trying to sell me something I’m pretty skeptical and demand a higher level of evidence to back up their claims. With KB, I would love to see a randomized study of women with post-childbirth incontinence who use her exercise techniques vs standard care.

      There are also some illogical statements and erroneous conclusions that I read. For exmaple, this idea that women in primitive cultures don’t have all the pelvic floor disorders that we have in North America and it’s because they squat all the time. Um…they also don’t have access to forceps and vacuums. Women with obstructed labour may die and so can’t go on to “develop” pelvic floor disorders. You get the idea…too many confounders. The other idea I didn’t like is that we should get back to our “caveman” roots, that we evolved to do certain things (like squat) and should organize our modern lives around stuff our great- great- great- great- etc ancestors would have done. Um…well, those caveman ancestors had a life expectancy much lower than what we enjoy today. Much of the stuff that adopting their “lifestyle” is purported to help you avoid wouldn’t have shown up before death due to “natural” causes. I wish she hadn’t gone there but just stuck to the biomechanics of the pelvis!

  5. I don’t have any urinary incontinence at this point, but I have had some very large babies (3 over 10 lbs) and I know that there has been some pelvic floor damage. I know this is just anecdata, but for me, there was a dramatic difference in the strength of my pelvic floor after my giant baby with epidural vs my giant babies without epidurals. Without epidurals, it took me months to have the ability to feel and use my kegel muscles again. With my most recent epidural birth, I was doing kegels within 2 days of giving birth, and that was a 10 1/2 lb baby. I won’t ever give birth without an epidural again knowing the difference it made in terms of offering protection to my pelvic floor.

    1. Laura · · Reply

      So curious about your findings: how did an epidural help protect your pelvic floor? (I’m so glad you found this out, by the way!).

      1. Here’s what I think happened in my previous unmedicated births of some giant babies (10 1/4 and 11 lbs.) I was simultaneously pushing AND bracing/clamping down against the pain because crowning with a big headed 11 lb baby? Excruciating. Traumatizing. Basically having to ram a very large object against clenched muscles.

        And I’ve never had tearing, but given that I couldn’t feel or use my kegels for months, I’m quite certain there was damage. Epidurals relax the pelvic floor and eliminate pain, so I was pushing over a relaxed pelvic floor this last time, not one clenched down as a response to the pain. I had thought that since I only really have pain for the pushing phase, that it wasn’t worth it to get pain meds, but at this point I don’t think I’d ever voluntarily give birth without an epidural again.

  6. If it makes you feel any better, it does eventually stop. I can’t speak to whether it’ll be back as I age, but I’ve had two babies, both with a 2nd-degree tear, and the urinary incontinence has largely vanished. Also…while the tear obviously makes it worse, in terms of pelvic floor weakness, I suspect (haven’t gone back to read the data) that pregnancy itself causes a lot of urinary incontinence, not vaginal delivery. My anecdotal reasons for this hypothesis are that my UI started (both times) while I was pregnant, and got better fairly rapidly once all that weight wasn’t bearing down on my lower body. I can now sneeze and walk at the same time again (and it’s been 9 months since my son was born).

    1. What you are saying is true…when it comes to incontinence, pregnancy is a risk factor. Tears are, I believe, an independent risk factor as well.

      Thanks for your kind words. You are right, it will probably get better and since it is pretty mild even now it doesn’t limit me much. However, since being physically fit and active is so important to me, I think it’s important to think about how I can protect and improve the remaining function in my pelvic floor.

      1. Oh, absolutely. I just wanted to be a slight ray of hope that “it will get better”. But, yes, among the things I have to do starting soon is to start being fit again. I’m trying to train for a 5K that’s in August…and finding that two kids + tenure-track job makes this really hard.

        (I was glad to read that Kegels don’t really help, though. I really, REALLY hate doing Kegels.)

  7. mrsstone · · Reply

    If I could have my three kids over again it would be via elective caesar. You say there is pain with weeing after a caesarian? Can’t be anything like the agony of urine on a fresh wound ‘down there’. And I totally agree regarding the drugs. I say all this as someone who has no obvious pelvic floor damage, but certainly can’t hold my bladder like I once could. I used to think elective caesars were for scaredy cats, but as I get older and see mums I know go through that process I envy how civilised the whole affair is.

  8. I had a c-section with my second child that was somewhat elective. With my first child, I had a 4th degree episiotomy. She was only 6 lbs but got stuck in the birth canal and had the cord wrapped around her neck. Using foreceps and the episiotomy she was extracted. She was briefly checked out by NICU and was perfectly fine. The recovery was horrendous. I could hardly sit on my bottom or make it up the stairs in my house. I was given both ibuprofen and hydrocodone, but they usually wore off pretty quickly. I had major swelling in that area for months and then when it healed there was extra skin left over that caused some issues. Eventually I had the extra flap of skin removed but I continue to have issues with passing gas. Prior to the birth of my first daughter, I could control when I passed gas. After the episiotomy, I found I had very little control. With time, this issue has improved but never returned to how I was pre-childbirth. When I became pregnant with my second daughter, I spoke with my doctor about the risks associated with having another vaginal delivery and the possibility of another 4th degree tear. Since I was already experiencing some control issues in that area, another vaginal delivery and possible tear could make those issues worse to the point that gas may not be the only thing I was not able to control. He supported us with any delivery decision we made and gave us the pros and cons of each. We decided to go with the c-section due the prior damage to my body as well as the fact that my second child was already in the 90th percentile at 6 months gestation which somewhat increased the concern that an episiotomy may be needed again with a vaginal delivery. My c-section was not technically all elective because there was some medical necessity behind the decision. It turned out to be the right decision because my daughter had 2 knots in her cord which could have complicated a vaginal delivery. The recovery from the c-section was nothing compared to that of the 4th degree tear. I hardly even needed the narcotic pain medication and mainly used ibuprofen. I also haven’t had any long term issues or damage to my body other than the scar. Fortuntely, I never had urinary issues but I credit that mainly to just genetics and having a super strong bladder. In one of my classes, I heard about a study involving urinary incontinence and nuns. The theory was that female urinary incontinence was mostly due to having children and being sexually active, but the nuns with age also showed incontinence. These were women who never had intercourse or gave birth to children. Therefore, urinary incontinence tends to increase with age no matter what we do and childbearing may just accelerate or worse the issue. The nurse in the class used this as an example of why Kegels are important for everyone. I found Kegels to be helpful with my issue as well, but as you stated there is improvement but it’s never back to how it was before childbirth.

  9. Jennifer · · Reply

    I have two children and a family history of pelvic floor disorders and have had two elective c-sections as a result of that. I am lucky that my OB’s have been understanding and honest about my risk factors and it was an option for me. My recovery from both surgeries was easy (part luck I know) and I don’t know why they are demonized so much by natural birth advocates. I certainly don’t recommend c-sections for everyone, but it’s odd that the risks of c-sections seem to be overplayed and the risks of vaginal delivery underplayed. I just want women to have the real truth to be able to make informed decisions. I have had two girls and if/when they have kids I will be sure to inform them they are c-section by choice children and why.

    Good luck with your issue and thanks for being honest about this. There is no shame in it and you DO have options to fix it. While you may not want surgery my friends who have had it have all reported wonderful results. It will get better!!

    1. I agree, in the political landscape surrounding childbirth these days, women are losing out. Access to accurate unbiased information is very difficult to come by. Back in the “good ol days” a C/S was always a last resort, in part because the mortality and morbidity from it was worse than a vaginal birth (I’m talking 100 years ago here). But now perioperative medicine has improved to the point where we need to majorly adjust our thinking on this issue and look at the evidence with fresh, non-politicalized eyes and trust that fully informed women will make the right choice for them. Since there is now no clearer “safer” route for the majority of women, it becomes a question of values.

      Of course, I don’t mean to say that there aren’t cases where either a C/S or a vagnial birthing route is the best due to medical issues…but for most women the choice probably comes down to a matter of conscience.

      I’m glad you had such a supportive OB. I know that mine is also supportive of maternal request C/S. Once we do an individualized risk assessment together, I’ll make a decision about birth method for future pregnancies. As it stands right now, my SUI is pretty mild and controllable with some minor behaviour modifications – so that is lucky. I’m not really limited in any way. My main focus is continued improvement and halting the progression of my pelvic floor dysfunction.

      1. supermouse · · Reply

        My mom needed the bladder sling surgery at age 53. She’d given birth (vaginally) to 2 girls, and both my sister and I were not large babies at all. She definitely noticed the UI was increasing with age, but 2 pregnancies and deliveries was considered a risk factor. They also did ovario/hysterectomy, which put her in immediate menopause, which she had not reached naturally at that point.

        I have only been pregnant once, but I have twins. The pressure on my bladder from the two babies was probably greater than most get from one. Also, they were vaginally delivered. I had a first degree tear, but that probably is not a major factor, as it was very small. Now, I have a touch of UI, if I cough. Unfortunately, winter of 2011 I had flu, followed by pneumonia, which meant I coughed a lot for a month. I had to wear panty-liners, so as not to leak on my clothes.

        I have heard that between pregnancy and pushing, the bladder can slip out of position (prolapse) which accounts for UI for many. As women age, skin/connective tissue lose elasticity, so if your bladder was already slightly prolapsed, it can get worse, simply due to aging. If this is true, I imagine I will have to have bladder surgery sometime in the future.

        Knowing what I know now, if I could do it over again, I’d probably have gone with the Csection. My OB offered it when I came in (SROM), but she said it wasn’t necessary (at that point, she wasn’t going to rule it out completely.) I was afraid of a painful recovery while trying to be a new mom to twins, so I said no. (Had a need arisen for a Csection at some point during L&D, I would have agreed to it in a heartbeat.)

  10. I just wanted to say thank you for writing this honest post. Urinary incontinence (together with other pelvic floor disorders) is a subject that has for too long been kept silent, and this often means that when women are injured during birth, they had no idea what the potential long-term repercussions might be. That’s not to say that every vaginal birth results in damage, but if antenatal educators believe women should be informed about all the possible risks associated with a planned cesarean, then they should inform them about all the possible risks assciated with a vaginal birth – or even trial of labor. But this is not happening.

    If I may mention it here, I have just written a book with the Canadian urogynecologist Dr. Magnus Murphy, and in it, we have a very long chapter on ‘Protecting Your Pelvic Floor’. This explains what happens to the pelvic floor during birth, and the various types of damage that can be caused and why. We haven’t written this to scare women, or because we believe that more women should have a cesarean, but rather because we are concerned that women are not being told the whole truth. Our book provides women with facts that they are unlikely to be provided with in many maternity care settings, and in an era where choice is available in virtually every other aspect of a woman’s reproductive life, we believe that cesarean birth is a choice that should be supported and respected too.

    Choosing Cesarean, A Natural Birth Plan (Prometheus Books)

    1. Jennifer · · Reply

      Thank you for writing this book! I actually purchased this AFTER both of my planned cesareans just because I wanted to support you in your effort to give women all the facts.

      1. Thanks so much for your support and feedback Jennifer!
        I really appreciate it.

  11. If anyone is considering surgery for SUI please do lots of research beforehand because there is a lot of controversy about methods which involve placement of a mesh implant (eg TVT) under the urethra. There are alternatives and you should research them all.

  12. Mrs. L · · Reply

    Thanks for such an honest post. I encourage you to talk to your OB about this. I did, and he made a referrel to a physical therapist in my area (large metropolitan city) who specialized in pelvic floor issues. Six sessions with her (and lots of exercises without her) and I’m back to pre-baby me. Good luck!

  13. Jenna · · Reply

    Be aware that SUI is also highly heritable. How do I know? My sister, who has had two children vaginally, has SUI, as does our mother, who had three… and so do I, though I’ve never even been pregnant!

    It sucks. Exercises help, though.

  14. Thank you for sharing. My experience: things really improve with time (of course, to a degree and temporarily). After my 1st vaginal birth (quite “tearful”), I had urinary incontinence during my 2nd pregnancy. Nevertheless, I progressed to another “tearful” vaginal birth. After it, I had not only urinary incontinence but twice, eh well, defecated outside home and far from any toilet. Though Earth didn’t stop revolving, the situation wasn’t pretty :-). Now, 5 years later, I have no major issues. My pelvic floor has partly healed and I have modified my behavior. I cross my legs when I cough or sneeze and I am very careful what I eat during my period when I am predisposed to diarrhoea (both unpleasant episodes were during period). I guess I will go to surgery some day to try and correct part of the damage, but I am not in a hurry.

  15. I wonder if you are aware of the book “Choosing Cesarean, a Natural Birth Plan”, by Dr Magnus Murphy and Pauline McDonagh Hull. It has a significant focus on protecting the pelvic floor. It would be really interesting to hear your views on it.
    http://electivecesarean.com/index.php?option=com_frontpage&Itemid=476_show.pl

    1. Read it! I thought it was a great book and would I would encourage all my pregnant friends to read it (although that does not mean I would encourage all pregnant women to have a c/s). It gave me a lot to think about, and a lot to discuss with my OB should there be a next time…:)

      Last weekend I saw a 70ish woman in the grocery store with a cart full of adult diapers, in front of my cart full of baby diapers…and I had a moment where I realized how important it was for me to do whatever I needed to do to not be that woman.

  16. Michelle · · Reply

    Hi
    May I know if you have recovered from your stress incontinence? I am suffering it too, doing kegels. 5m pp.
    thx.

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