Incontinence and Childbirth

You’ll find no mention of incontinence in prenatal classes or in parenting guides. But ask a soccer mom or baby boomer about ‘leaking, pads, and diapers’ in private, and you’ll likely hear a personal story, see a surgical scar, or be asked the question, “You mean that’s not normal at my age?” Among mothers of all ages, incontinence and other pelvic problems are discouragingly common.

  • Urinary incontinence affects 30-50% of childbearing women by age 40. Up to 63% of stress-incontinent women report their problem began during or after pregnancy.

  • Fecal incontinence, defined as loss of control over gas or stool, affects up to 25% of childbearing women, often resulting from injury during birth.

  • Pelvic prolapse refers to weakening around the vagina, uterus, and pelvic floor. Common types include cystocele (dropped bladder), rectocele (bulging rectum), and uterine prolapse (dropped uterus).

For too long, these problems have been regarded as inevitable costs of motherhood – but attitudes are changing. Life after childbirth does not need to entail a routine of pads and liners, or a struggle with symptoms at home or work, at the gym, or in the bedroom.

The Most Important Physical Event of Your Lifetime

Whether childbirth is easy or difficult, long or short, one fact remains constant: your body will never be exactly the same after pregnancy and delivery, as it was beforehand. And while learning ‘what to expect while you’re expecting’ is important, knowing what to expect afterwards is the key to prevention. Indeed, decisions made during pregnancy and childbirth may impact your bladder and pelvic function for years to come. A few areas of your body are particularly important:

  • The perineum lies between the vaginal and anal openings, the area cut with an episiotomy. Injuries may create vaginal ‘looseness’ or bowel problems.

  • Levator muscles provide key support for the pelvic organs – helping to maintain control over bladder and bowels. After childbirth, muscle strength is usually reduced.

  • Pelvic nerves maintain strong and healthy levator muscles. Nerve injuries, especially common after a long or difficult delivery, are associated with incontinence.

  • Connective tissues help to secure the pelvic organs in place. During childbirth they routinely stretch, tear, and weaken.

  • Your pelvic bones have a unique size and shape, which may influence the physical ease or difficulty you might encounter with childbirth, and the extent of pelvic injury.

Preparing Your Pelvic Floor for Delivery

As your due date approaches, it’s easy to overlook one of the most important issues: your body. But would you enter into any other major physical event without stretching, working out, and getting yourself into shape? Start early. Prevention should begin with your first baby, since this one appears to carry the greatest risk of injury. Kegel exercises can decrease incontinence, and your first pregnancy is one of the best times to learn about them. Not only because the need is so great – up to 70% of women have some leakage during or after pregnancy – but also because the muscles are still at their greatest potential. Perineal massage involves gentle stretching of the vaginal opening, and may decrease the risk of birth injury and pain afterwards. Weight gain and fitness may influence the risk of incontinence. Learn about an appropriate diet, exercise routine, and posture and lifting tips – including ‘bracing’.


Learning How to Labor

Several aspects of childbirth that may seem inevitable are, in fact, choices to be considered.  Early labor relaxation - pelvic floor tension, due to pain or anxiety, can slow your progress during early labor, and a relaxation strategy can help.

Labor pushing introduces tremendous strain on the pelvic floor. Though there is no one ‘best’ pushing, you should know your options.

  • Which position? Although lying down on your back (lithotomy) is most common, alternatives include squatting, sitting, sidelying, and standing. Certain positions might influence the risk of pelvic or perineal injury, such as back lying with legs strapped in stirrups.

  • When to begin? Recent studies indicate that for some women, difficult deliveries, forceps, and perineal injury may be less likely with delayed or less forceful pushing, by allowing the fetus to ‘passively’ descend through the birth canal.

  • For how long? Prolonged pushing may sometimes increase the risk of pelvic nerve injury, fecal incontinence, and bladder dysfunction. You may wish to discuss reasonable ‘limits’ for pushing ahead of time with your doctor or nurse midwife.

Episiotomy refers to the intentional cutting of the perineum during childbirth. Contrary to past beliefs, today it’s known that episiotomies are rarely of benefit in terms of preventing injuries to the pelvic area. However, ‘selective’ episiotomy remains an important tool, and sometimes, the best care for baby and mom.

Forceps delivery carries an increased risk for urinary incontinence and injuries to the anal sphincter and pelvic floor compared with spontaneous vaginal birth. The use of a ‘vacuum’ may be associated with less pelvic floor trauma.

Big babies are associated with more severe perineal, rectal and pudendal nerve injuries, and incontinence. If you are carrying a ‘macrosomic’ (9 pounds or more) baby, be sure to understand these issues.

The ‘Cesarean by Choice’ Debate is surrounded by complex medical, economic, and social questions. In parts of South America, cesarean rates exceed 90%, whereas trends in Europe have favored vaginal birth whenever possible, even if it entails a long or difficult labor. Determining the ‘right’ policy will require more research. In the meantime, know the facts.

  • Consider the risks. Although a c-section is safer today than at any time in the past, it still carries potentially serious risks for mother and baby.

  • Consider the benefits. Urinary incontinence, anal injuries, and pelvic prolapse are less common after cesarean. The most protective appear to be those performed in the first pregnancy, before labor begins.

  • Individualize your choice. Most obstetricians and midwives share the goal of a vaginal birth whenever the benefits outweigh the risks. The challenge is to identify women at risk for serious injuries who should be offered cesarean as an alternative. In some cases, a difficult vaginal delivery may be more physically traumatic than a cesarean. For others, the exact opposite will be true.

What Can Be Done After Delivery To Prevent Problems?

Physical recuperation after childbirth is substantial – and too often overlooked. Alongside the diaper changes, you should take steps to rehabilitate your pelvic floor. Preventing perineal swelling and infection may involve ice packs and proper hygiene to prevent infection. Avoiding constipation will reduce strain against the pelvic floor. Pelvic floor muscle exercises will help to restore muscle function before it is permanently lost and lessen the symptoms of incontinence. Pelvic floor muscle exercises are often referred to as Kegel exercises – after Dr. Arnold Kegel. At the time, Dr. Kegel conceived of this therapeutic protocol, the therapy included biofeedback (see photo of biofeedback equipment) and pelvic floor physiotherapy to ensure the pelvic floor muscles were being properly exercised. Strictly speaking, the term Kegel refers to the integration of biofeedback therapy. Women who have difficulty performing pelvic floor muscle exercises on their own may find that biofeedback therapy with the help of a nurse specialist or physical therapist enables them to witness significant improvement in pelvic floor strength. Sensible work and play. Leaping into a strenuous routine may stress your pelvic floor before it has healed. Be informed about exercise, dietary, and lifting habits. If problems persist … see a urogynecologist. Incontinence and pelvic floor symptoms almost always have solutions and shouldn’t be shrugged off as ‘normal’.

New Perspectives on Childbirth … and Women’s Health

Incontinence and pelvic problems are remarkably common and can severely impair a woman’s quality of life. These problems are not inevitable. Informed decisions made during pregnancy and delivery can reduce your risk of future problems. Prenatal visits should include discussion of labor and pushing styles, fetal and pelvic size, forceps and episiotomies, cesareans, and other factors that may influence your function afterwards. Though childbirth will always involve unforeseen ‘twists and turns’, you can make your experience one based more upon choice than chance. These areas of your body, and aspects of your future comfort and control, deserve a place in your childbirth planning.