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?