Pelvic Floor Disorders and Method of Childbirth
Monday, October 17, 2011 at 6:09AM
By ANaturalAdvocate
The October issue of The Green Journal includes a new article about pelvic floor disorders and method of childbirth. Many women say that fear of incontinence impacts their approach to childbirth, with some women choosing elective Cesareans specifically to prevent pelvic floor damage. The article, with Dr. Victoria L. Handa as lead author, discusses whether these concerns are accurate, and how they might impact method of childbirth.
The study looked at women 5-10 years after their first delivery, all of whom had delivered at Greater Baltimore Medical Center, classifying each woman by method of delivery:
- cesarean without labor
- cesarean during active labor
- cesarean after complete cervical dilation
- spontaneous vaginal delivery
- operative vaginal delivery [including forceps and vacuum extraction]
If a woman had deliveries that fit into more than one category, she was classified according to the method of delivery that the authors felt had the highest likelihood of causing pelvic floor injury. The classification was determined by a review of obstetrical discharge records.
The authors then measures rates of four types of pelvic floor injury:
- stress incontinence
- overactive bladder
- anal incontinence
- prolapse (defined as at or beyond the hymen)
The injuries were first assessed through questionnaires given the women in the study, and then confirmed or re-assessed through physical examination. In addition, women who had undergone surgery or prior or current therapy for a specific pelvic floor disorder were considered as having it, even if they did not currently show symptoms.
The authors also looked at race (self-reported), maternal age at first delivery, obesity (measured by BMI at study enrollment), and cigarette smoking (“classified as ‘never’ or ‘ever’ based on whether a woman had smoked at least 100 cigarettes in her life”).
The authors concluded that a woman who had had at least one vaginal birth was “significantly more likely” to report stress incontinence or prolapse, but that “the most dramatic risk was associated with operative vaginal birth.” Symptoms of prolapse were uncommon across all groups but interestingly only 19% of women with prolapse reported “bothersome symptoms” from the prolapse; women who were obese upon examination or over age 35 at time of first delivery were more likely to report symptoms. The authors hope to continue to follow the women to determine whether those with reportable symptoms of prolapse were more or less likely to progress or regress.
Anal incontinence and overactive bladder were also both “significantly associated” with operative vaginal delivery but not spontaneous vaginal birth.
The authors found no difference in the rates of pelvic floor disorders in the cesarean groups, which is interesting considering that previous studies had indicated a link between active labor before a cesarean and pelvic floor injury. They did indicate, however, that the rate in each group was so small that an increase may not have been detectable under a doubling of the odds.
The study was limited by the small number of pelvic floor injuries in the group as a whole, and the low participation rate (50%) of all eligible women (based on medical records). “In addition, this is an observational study and we therefore cannot with certainty ascribe the incidence of pelvic floor disorders to obstetric events. We cannot exclude the possibility that unmeasured characteristics of the population or other exposures were relevant to the development of pelvic floor disorders.”
What do you think? What information did you have regarding possible pelvic floor disorders before giving birth? The authors state that they hope the study - which will continue looking at the cohort over time - “will be useful to women and their obstetric providers as they weigh childbirth options.” Does the information in this study impact how you view various methods of childbirth? What would make you change your mind, if anything, regarding pelvic floor disorders and childbirth? What other factors do you think might impact the rate?
Edited to add the chart showing exact numbers and percentages of pelvic floor disorders by childbirth method, race, age, parity, body mass, and smoking.
Chart courtesy of The Green Journal.
Reader Comments (21)
I wish there were a pithy unnecesarean-style phrase for "unnecessary forceps delivery," because I'm still pissed about it a year later. Mostly when I run.
I wish they gave actual numbers on the occurrance of these problems. You know, if 50% of women are soaking their pants every time they sneeze after a vaginal birth, that is significant. But if it is 0.05% who have a slight bit of wetness when they sneeze...well sheesh, what are we all up in arms about? I've heard that "anal incontinence" can actually just mean inability to controllable farting. Certainly not socially pleasing...but when I compare it to the risks of cesarean, I'd opt for that.
There's a huge body of research out there on this subject. Unfortunately not many people seem all that interested in sharing it with women before these problems occur, when they can still consider their risks and make appropriate choices.
It's really a drag to be forced into natural childbirth when it's something that has little or no value to you depending on your beliefs, and ending up with a nightmare of problems that significantly impact your life and could pretty easily have been avoided had you a) been completely informed and b) been given the autonomy to make your own decisions based on your own preferences and risk tolerance.
Having a significant PFD can be the beginning of many years of shame, humiliation, and pain. It can limit your ability to participate in sports and can affect your intimate relations. You can emerge from childbirth thinking that you've escaped surgery only to find yourself facing a never-ending ordeal of invasive exams and surgeries-- only these aren't limited to your abdomen. I believe a recent study suggested that something like 1 in 10 women will undergo surgery for these problems during her lifetime.
Thanks for drawing some attention to the topic.
Knitted in the Womb: The study actually does have the numbers; I will update the post with them now.
I just wish that they would adjust for women who did or did not do their kegels. I did mine and yeah, right after birth, I'd have a little wetness, but just kept on with the kegels and by two months later, right back to normal. But what if you never keep working at the exercises and just have 3 kids back to back? I don't know how much that affects it.
I have been a pre and post natal exercise specialist for 15 years. Since the birth of my first child I have changed how I train women during their pregnancies. This is my story on Pelvic floor issues http://pregnancyexercise.co.nz/information/pregnancy/how-much-pelvic-floor-muscle-exercise
I wish someone would study the incidence of pelvic floor injuries comparing methods and positions of pushing. I am inclined to believe that forcing a woman onto her back (or even the c-curl) and/or urging her into valsalva-style pushing increases the likelihood of pelvic floor damage. It would be nice to have some research to back up that belief and then compare those figures to ones from a study such as they above.
Pelvic floor muscle exercises (kegels) can be helpful, but they're never going to do much for women with more extensive injuries. Building up some muscle strength can't compensate for significant tears or damage to connective tissue, muscles, or nerves.
I know it's fashionable to blame these problems on obstetrical technique, but I can't think of any reason to believe that any particular pushing position would be protective.
I know it's fashionable to blame these problems on obstetrical technique, but I can't think of any reason to believe that any particular pushing position would be protective.
Well, that's revealing language. It assumes that these injuries were an inevitable* risk of vaginal birth and assumes the current level of risk is inherent to vaginal birth. Thus some "other" position(s) might be "protective." Rather than that the most typical position(s) in US hospitals carries an increased risk over mothers being allowed to choose whatever feels most comfortable, waiting for the pushing urge (when possible), etc. Not to say that we have hard data on this, but just saying that the choice of words was revealing of a bias (meant neutrally, as we all have biases). The assumption that the current "standard" is some sort of gold standard-- and this hardly applies only to birth-- is really faulty and dangerous. Especially when the above statement implies that we don't know whether it is gold or not. If we don't know, then how is the assumption that it is gold any more valid than that it is harmful? Aside from a bias towards authority figures and tradition, which makes little sense given the known history of obstetrics-- and medicine, and anything, for that matter. And I say that in as neutral and factual a way as possible. Even if we give some credit to authority and tradition, it's hardly the final word on the matter.
I apologize if I missed this, but I am running out the door-- but where is episiotomy in all this? Without more information, I must assume that having an episiotomy did not preclude inclusion in the "non-operative" vaginal delivery group. Or did it?
I think it's really important to make women aware of ALL of the risks of EVERY choice that can be made in childbirth. To act like one choice is risk-free and the other is not is insulting and injurious, whatever those choices may be, and however necessary they may be or one may feel they are.
*Surely some percentage is-- whatever that percentage may be.
Oh, and FWIW, I don't think kegels have been shown definitively to do much, on the whole, when looking at any cohort of significant size. Though if anyone wants to show me the studies, I'd be happy to read them.
I too would be interested in seeing pushing position considered. It seems that squatting, which opens the pelvis further, might prevent pelvic floor damage. The study also doesn't control for epidural use. Because epidurals often dictate that others (or the monitor) must tell a woman when to push, she may be pushing differently or harder than a woman birthing without numbness, and she may not be able to adjust he position to one more conducive to birthing. Finally, this study was done at a suburban hospital known for catering to wealthier moms. Note that even though the facility is just ourside Baltimore City, a very small proportion of participants are African American. I would hesitate to extrapolate from this limited demographic. With only half of the population of birthing moms at the facility being included in the study, I'm surprised the results were published at all. I'd have to read the whole study to determine whether this astoundingly compromised sample maintained any validity, but any participation rate under 80% is usually not considered to be valid for statistical analysis. I do think the paper covers an important topic and hope it will be addressed with better data in the future.
This study is not remotely groundbreaking or controversial. There are piles of articles, as well as specialized journals and textbooks, detailing the nature, extent, and frequency of damage that commonly results from vaginal birth.
Further, these conditions are quite common in areas where western obstetrical care is not the norm.
Frankly, it's ludicrous to suggest that pushing position has a thing to do with it. I can only interpret that as another attempt to deflect criticism by placing blame on both the injured woman and her caregivers for not doing things the "right" way (whatever your narrow, idealized version of that happens to be at the moment) and therefore being deserving of a less than positive outcome.
Yttrbia: While I agree that there's nothing particularly earth-shattering about this study, you seem very concerned that any study that branches out into confouding factors such as induction, positioning, etc., would be used to "blame" women and/or their providers for "doing something wrong." Is it not possible to study these issues to be able to give more information to the women and their providers, to choose what is best but with more data? "Optimal" positioning (whatever that might be) may not be possible for a woman for a particular reason, but knowing that she might be at slightly higher risk for pelvic floor injury because of the position she did end up birthing in might give her and her provider information that could be used to improve her recovery and care, yes? I think the "optimal/perfect/whatever" birth is probably not possible for a lot of women for a lot of reasons, but that doesn't mean that we should not try to found out how to prevent/decrease injuries and complications with an eye to optimal *health* for mother and child.
Is there any way to stop the spam? Maybe having us type in one of those (pardon my non-tech language) distorted words or character strings? I appreciate the conversation, but not the prevent pelvic floor disorders by buying a Rolex.
"but not the ADVICE to prevent....." Sorry, fingers don't work without coffee.
Aron: Apologies for the spam. When we put in filters commenting went way down (plus CAPTCHAs and such are often hard for some). We try and delete it quickly, but sometimes it's not as quick as we'd like.
Is it me, or are those operative exposure groups broken down to be so small that even a low incidence of a problem in a group might appear significant? Only 325 women in the spontaneous vaginal delivery group, and that's the largest group? I totally understand that one study cannot be all things at once, but with small sample sizes like that, it would be easy for another factor (episiotomy, pushing position or duration, etc.) to influence the results in a big way. I would also like to see the aggregate number (am I missing it?) of women with any pelvic floor injury, since it is likely that some women have multiple problems vs. many women having a single problem.
Yttrbia, I sense that you may have an agenda involving emphasizing the potential consequences of vaginal delivery because you feel "forced" into NCB and would prefer an elective cesarean section, but I don't think that justifies not trying to find out why some women have pelvic floor injuries from vaginal deliveries while the majority of women do not. Perhaps we could use such information to decrease the percentage of women who have a pelvic floor problem after delivery, and that's good for women.
ANaturalAdvocate,
I don't think that studies of the sort you mention would be particularly feasible or meaningful. With all due respect, I think your desire to tie these problems to factors relating to obstetrical management reflects a narrative that is common in natural childbirth circles, i.e., that most complications in childbirth are caused by medical interventions, with the corollary that you can avoid most complications by avoiding interventions. Any study of the sort you are suggesting would almost certainly be useless because you simply can't randomize factors like pushing position or induction, and there are too many potential confounding variables for a correlational study to be worth much.
And no, I'm sorry, but I don't think knowing what position a woman pushed in would provide much, if any, useful information to a surgeon attempting to repair bladder or rectal damage or performing a hysterectomy.
Realistically, the only thing a woman can really do to prevent these problems is to have a c-section, and I think all women should know that that is an option.
No worries. It just seemed like there was more than usual.
To restart the topic I threadjacked, according to this article from Medscape (http://www.medscape.com/viewarticle/578731_2) provider management of pushing and pushing position are directly linked to the incidence of pelvic floor injury:
"Perineal trauma is directly related to use of oxytocin, mechanical maneuvers of perineal protection, delivery position, second-stage duration, and continuous fetal monitoring (Albers et al., 1996; Albers & Borders, 2007; Roberts & Hanson, 2007). Fa vorable results to the perineum may be associated with left lateral birth position, spontaneous pushing, non-use of oxytocin, support person of the woman's choice, and excellent CNM or provider care (Caroci de Costa & Riesco, 2006). Hands-on interventions contribute to a more interactive presence with the birth attendant, which women prefer, and these factors are sometimes more important than implementation of protective techniques for the perineum (Albers & Borders, 2007; Albers et al., 2005; Caroci de Costa & Riesco, 2006; Roberts, 2002)."
Another excerpt from the same article: "In contrast to the traditional lithotomy position (supine with legs in stirrups), upright and lateral birthing positions have been found to have many benefits to the delivering mother. These include shorter second stages, reduction in assisted deliveries, fewer episiotomies, and reduced anterior and perineal tearing (Albers & Borders, 2007; Roberts, 2002; Roberts & Hanson, 2007). A study composed of 3,049 women with midwife-assisted births indicated that perineal support (including warm compresses and counter pressure against the fetal head) during delivery while maintaining the woman in left lateral lying position can reduce the frequency of degree of perineal laceration when compared to the more common lithotomy position (Albers et al., 1996). The lithotomy position is associated with factors that may predispose use of episiotomy, such as fetal bradycardia and prolonged second-stage labor."
Essentially, the way in which a provider manages second stage (including the position mom is place in, directed vs. non-directed pushing, hands on vs. hands off deliveries, etc.) directly contributes to the likelihood of a woman sustaining pelvic floor damage.
Yttrbia: I hear what you are saying, but I don't think you are listening to me. My goal is for women to have autonomy and make informed choices. I do not think the information at hand sufficiently answers the question of how risk is increased. I do not say that the plural of anecdote is data, but with the amount of anecdata available regarding this (from sources other than this as well, and including with PFDs after vaginal delivery and not, etc.) I don't think dismissing out of hand the idea of further study is appropriate.
That said, I would like to repeat that my goal is for women to have access to the information necessary to make an informed decision. Even if the data shows no increased risk in vaginal birth (operative or not), but a woman's particular fears/needs/beliefs/whatever combine with the available data to convince her to choose a cesarean, I support that decision just like I would support another woman in the same position choosing a vaginal delivery.