Rachel L. Parker


         
         1.	DEFINING INCONTINENCE
         
         2.	HOW THE BLADDER NORMALLY WORKS
         
         3.	DIAGNOSING INCONTINENCE
         
         4.	CHILDBIRTH  AND INCONTINENCE
         
         5.	TREATING INCONTINENCE WITHOUT SURGERY
         
         6.	TREATING INCONTINENCE WITH SURGERY

7.	INTERSTITIAL CYSTITIS with Leslie Kaplan, MD
         
         8.	DEFINING AND DIAGNOSING PROLAPSE (PELVIC RELAXATION)
         
         9.	TREATING PROLAPSE WITHOUT SURGERY

11.	ANAL INCONTINENCE with Tracy Childs, MD

 The Incontinence Solution: Answers for Women of All Ages

Articles

This book is written to give understandable answers to women suffering from Incontinence.  It explains the condition and gives realistic options to those suffering from this embarrassing condition.  I read it and learned much from it.

The Incontinence Solution: Answers for Women of All Ages

CHILDBIRTH AND INCONTINENCE: THINGS YOU SHOULD KNOW


         "I'm willing to do whatever it takes to fix this," said Phoebe  when she came into the office about 4 years ago.  This beautiful, 34  year old redhead was at the end of her rope due to incontinence. "It is  strangling my life," she said.  She had emigrated from England 10 years  before, married a local man who worked as a hairdresser, and was now the  mother of two young children.  Her first child was 8½ pounds at birth,  and Phoebe had a long and tiring labor ending with two and a half hours  of pushing before delivering a healthy baby girl she named Cara.   Following delivery, Phoebe had some mild urinary loss when she laughed  or coughed, but this problem went away almost completely after about 6  months with time and the use of Kegel exercises.   She was able to  maintain control over her bladder most of the time, and life just went  back to normal. 
         
         Phoebe's second pregnancy went smoothly, and her labor was a bit  easier than with her first. The delivery was hard though, and the  doctor needed to use forceps to deliver her 9- pound son, Gerald.   Phoebe again experienced urinary loss after Gerald's birth but assumed  it would go away as it had done with her first child.  When we saw her,  Gerald was two years old, and Phoebe's urinary loss had gotten worse.   She had already given up aerobics classes, and she leaked with nearly  every cough, sneeze or laugh. 

Phoebe was a waitress in a pub that catered to British  ex-patriots in our area, and she was seriously thinking about quitting  her job.  She was on her feet from mid-day until late evening and in  order to get through the day needed to change a large pad every few  hours.  Since many of the customers knew her well, she often took a lot  of ribbing over her red hair and having married a Yank.  The atmosphere  was friendly, boisterous and often funny. 
         
         The last straw with her incontinence came about because of the  funny part.  One evening as she was bringing a tray of drinks to a  table, she overheard Ian, a frequent customer who was a hangdog, broke,  and out of work store clerk, tell a pretty newcomer to the bar that he  was a pilot for British Airways flying out the next day to the Bahamas.   Phoebe made it past Ian and burst into laughter when she got back to  the bar.  But, the laugh was costly; her fortunately dark colored pants  were now good and wet, and her shift was not over for an hour.  Phoebe  called our office the next day. 

When we took her medical history, the difficult labor with  her first child and difficult delivery with the second stood out as  warning signs of possible damage to her urinary system.  Our examination  showed there was a weakness of the pelvic muscles supporting the  bladder. We thought further testing was needed to be sure that no other  bladder problems existed, and so urodynamic testing was performed. The  results of the examination and urodynamics showed that the problem was  primarily weakness of her pelvic muscles and ligaments that were  allowing the bladder to come out of position when Phoebe laughed,  coughed, sneezed or exerted herself by lifting heavy trays at the pub.  Called stress incontinence, this is the most common type of incontinence  following childbirth. Phoebe asked what had caused her problem.  We  answered that although there are a number of things that can lead to  damage to the pelvic muscles and nerves, the most common is childbirth.   Fortunately, there are a number of good treatments available to fix  Phoebe's incontinence.


         Everyone who has had a child knows that once a baby is born,  life is never the same again.  Women also know that their bodies are  never exactly the way they were before they gave birth.  Recent evidence  tells of just how different a woman's body may become after labor and  delivery. Women who have not delivered a child vaginally rarely develop  incontinence or pelvic muscle relaxation, while women who have vaginal  deliveries sometimes do.   Again, be assured that most women will not go  on to develop incontinence after childbirth. 

This chapter is to help you understand what we know about why  some women who delivered babies have problems with incontinence, but it  may also cause you concern about those women yet to deliver or yet to  even conceive.  Will their ability to stay dry when they get older be  compromised by childbirth?  What should they do?  What should they be  told?  Understand that we are still at an early stage of fact-finding  for this new information, but this chapter will consider the answers to  these questions. 

There are many factors that can lead to incontinence - the  strength of the pelvic supporting structures that you were born with;  the forces these structures have resisted over the years, including  childbirth, heavy lifting, and straining during bowel movements; your  ability to heal if these tissues are injured; the effect of the ageing  process on the collagen that gives strength to these structures.   Probably no one factor is completely responsible for the development of  incontinence.  Further research is needed to help clarify the importance  of each possible cause and the interplay between them. This research  will likely benefit those women who are yet to have children. 

We do know the connection between incontinence and childbirth  has been implied for a long time. When gynecologists see women for  problems of incontinence, they are not surprised to find the most severe  problems often in those women who had many children or who delivered  large babies.  Recently doctors started working out the details of these  relationships and are looking for the specific reasons why some women  go on to develop incontinence and other women never have this problem.  Although the studies are preliminary and involve only small numbers of  women, some details are starting to emerge.

About 10-20% of women who have a vaginal delivery will be  bothered by prolapse, bulging of the bladder, rectum or uterus into the  vagina, by the time they reach 50 years old. Women who deliver one child  have a 3 times greater risk of developing prolapse than women who have  not had children. Women who delivered two children have a 5 times  increased risk, and women with four or more children have an 11 times  greater likelihood of developing this problem.  Women who need to push  the baby out longer than one hour or who deliver larger babies appear to  be at a greater risk of developing incontinence later in their lives.  There is increasing evidence that childbirth is responsible for much of  the injury to the muscles and nerves of the pelvis.  This injury  eventually leads to urinary loss and pelvic prolapse.  Most women are  not aware of this somewhat new information. In fact, many doctors are  not apprised of the recently collected data.  This chapter explains what  we know, so far, about incontinence and childbirth. 
         
         


         The modern movement of childbirth education is enormously  important in helping to educate women about labor, childbirth,  breastfeeding and caring for a newborn.  Doctors rarely have time to  talk with their patients in any detail about the steps of labor and  childbirth, and childbirth educators fill this need well.  Many  childbirth educators also focus on avoiding medical interventions that  interfere with a "natural" birth, especially cesarean section. Lamaze,  the Bradley method, and many midwives and doctors encourage women to  labor as long as needed and as long as the baby's health, as monitored  by the heartbeat, can tolerate labor. As a result, prolonged labor or  prolonged pushing is sometimes encouraged in order to avoid a cesarean  section.  However, while safe for the baby, it appears that these  concepts may not be in the best long-term interest of the mother.   We  know now that prolonged and difficult labors may lead to permanent nerve  damage and weakening of the pelvic muscles and the supporting  structures to the uterus, bladder and rectum.  This can eventually lead  to dropping of the pelvic organs or incontinence. 

As every woman who delivers a child knows, labor and delivery  subject the body to forces that are not encountered in any other  circumstance.  Muscles and nerves in the pelvis are especially affected.   As the baby's head comes down into the pelvis, it presses against the  muscles that line the inside of the pelvis.  The farther down the baby's  head goes into the pelvis, the greater the pressure against these  muscles and underlying nerves. After the cervix is totally dilated, the  pushing phase of labor begins.  The mother is usually asked to wait for a  contraction to start, then hold her breath, and bear down as hard as  she can in order to push the baby out. This bearing down presses the  baby's head against the mother's muscles and nerves to such an extent  that the normal flow of blood is cut off temporarily until that push is  over. Without a fresh supply of blood, the tissues are deprived of  oxygen and nutrition, making them more susceptible to damage. The  pressures generated by pushing are 3 times higher than the tissues would  normally tolerate for any prolonged time.  However, the few minutes of  rest in between contractions usually lets blood flow back to the area.  This fresh blood carries oxygen and nutrition to the muscles and nerves  and carries carbon dioxide and waste away. The few minutes between  contractions are normally enough for the tissue to recover. 

However, unless delivery occurs quickly, the baby's head  continues to be pressed against the tissues. For some women this  pressure can cumulatively add up to many hours. Two nerves, called the  pudendal and the pelvic nerves, lie on each side of the birth canal  within the muscles that are directly under the baby's head.  Because  they are so close to the baby's head, these nerves are especially  vulnerable to the pressures of labor.  The pudendal and pelvic nerves  carry the signals from the brain to the muscles that hold the bladder  and rectum in place.  If these nerves are injured, the signals meant for  the muscles around the bladder, vagina, and rectum may not be  transmitted properly.  Without stimulation from the nerves, the pelvic  muscles, like any underused muscle in the body, can become weak and  flaccid. Some studies show changes in the function of these nerves in  more than half of women following vaginal delivery. Interestingly, a  prolonged labor or pushing phase before a cesarean is performed makes it  likely nerve damage has already happened even if the baby is eventually  delivered by cesarean.  Over time and with age, the normal supporting  tissues of the bladder, rectum and uterus weaken, adding to the effect  of childbirth injury.  The result can be incontinence of urine or stool,  or prolapse. 

Some recent studies show that the likelihood of incontinence  and prolapse is lower if the mother (and her doctor) allow the natural  force of the uterine contractions to push the baby down the birth canal,  rather than have the mother push as hard as she can during this time.   If the voluntary pushing part of labor can be limited to less than one  hour, studies show a lower incidence of injury to the nerves and muscles  of the pelvis. This alternative may be a safer and more natural way to  deliver by letting the uterus do the work it was designed to do. 
         
         

CAN VAGINAL DELIVERY LEAD TO INCONTINENCE?


         As part of the extraordinary forces on a woman's body during  delivery of the baby, the pelvic tissues may be subjected to damage. As  the head comes out, the forces can actually tear the ligaments that  anchor the pelvic supporting muscles to the pelvic bones. The muscles  themselves may also be damaged. (see fig 4-1) Sometimes the muscle near  the outside of the vagina is intentionally cut by the doctor to help  speed up the delivery. We now know this cut, called an episiotomy,  increases the risk of anal incontinence. 

For some women these damaged muscles and ligaments remain  weak and do not entirely heal.  As time goes on and the normal changes  of aging and weakening of the tissues takes place, incontinence may  result.  At present, only sophisticated and expensive tests like MRI or  nerve conduction studies can tell if these muscles and nerves have  returned to normal. Unfortunately, there is no convenient, easy way at  this point for you or your doctor to know if these muscles are weakened  and destined to lead to incontinence. Nor is there presently any remedy  for nerve damage.
         
         

WHAT ROLE DOES FORCEPS DELIVERY PLAY IN INCONTINENCE?


         Forceps increases the risk of injury to the nerves and muscles  of the pelvis. Forceps are the spoon-shaped metal instruments that are  sometimes inserted into the mother's vagina and placed around the baby's  head at the time of delivery. These instruments are usually used after a  long or difficult labor to help deliver a baby. As the doctor pulls on  the forceps, they push away the muscles and soft tissues in the pelvis,  allowing more room for the baby to come out.  The forceps also help the  doctor to pull the baby out, especially if there is a tight fit.   However, because the instruments are made of metal and take up space of  their own, they increase the risk of stretching and tearing the vagina  and supporting tissues of the pelvis. They also put more force against  the nerves that run inside the pelvis. As a result, more harm can be  done to the tissues, possibly resulting in long-term damage and eventual  incontinence. 

Forceps were invented in the 1500's, at a time when cesarean  section was commonly fatal for the mother. Forceps offered women a  lifesaving alternative in the event of a difficult birth.  The  development of forceps constitutes both an innovation and a stain on the  history of obstetrics. Forceps were invented by Peter Chamberlain, a  French physician, in the 16th century.  Despite the urgent need for  them, these instruments were kept secret by him and his family for the  next three generations, about 100 years. This secret allowed the  Chamberlain family to promote the idea that they were more skilled than  other obstetricians and could deliver babies where others had failed.  Since medical practitioners outside the Chamberlain family had no  knowledge of these lifesaving instruments, many women died needlessly.   In the late 1600's, one of the Chamberlains sold the idea of the forceps  to another physician, who went on to license their use for a fee.

In time the knowledge of forceps spread, and many  obstetricians became trained in their use. The proper use of forceps  became a hallmark of trained obstetricians.  Midwives were forbidden to  use them, and this is still true today. Even in the early 1900's, the  risks associated with cesarean section including infection, bleeding,  anesthesia and death, far outweighed the risks associated with the use  of forceps. A forceps delivery was state-of-the-art obstetrics for a  time, and many women and children survived childbirth because of them.  However, by the late 1900's, surgical and anesthetic techniques  improved; antibiotics made infection less dangerous, and blood  transfusions prevented many deaths from hemorrhage.  These factors made  cesarean section safer.  In addition, it became apparent that the metal  arms of the forceps were not always kind to the baby's head. On rare  occasions, small skull fractures can result and sometimes lead to  permanent injury to the baby.  Consequently, cesarean section became the  accepted tool for the obstetrician to use in a long or difficult labor.

Because there is a risk of complications with forceps to  mother or baby, they should probably not be used to deliver a baby  unless there is a rapid drop in the baby's heartbeat, severe bleeding or  other emergency that dictates a quick delivery.   While forceps are  used less often now, the use of an instrument called the vacuum  extractor has increased in the past ten years. The vacuum extractor may  be safer for the mother, but it may not be entirely safe for the baby.   This instrument has a soft plastic suction cup that is attached to a  handle. The obstetrician applies a suction cup to the top of the baby's  head, and it hardly touches the mother at all.  The doctor pulls on the  handle while the mother pushes, and the combined effort can help deliver  the baby.  However, recent studies show a very slight increase in the  risk of injury to the baby's head with this device. As a result, even  the vacuum extractor may be used less in the future.

DOES CHILDBIRTH INEVITABLY LEAD TO INCONTINENCE?


         Despite all the forces the pelvic tissues endure during labor  and childbirth, incontinence is not inevitable.  In fact, a woman's body  is remarkably resilient, and the vast majority of women who give birth  do not develop incontinence.  In most cases, the damage created by  childbirth repairs itself over time as the tissues go through the normal  healing process. The majority of women experience no residual effect  within just a few months after childbirth.  Almost half of all women who  have a vaginal delivery show immediate recovery of the nerves' ability  to carry messages to the pelvic muscles, and 60% will have complete  resolution within two months.  However, in some women, the injured  tissue does not recover 100% of pre-labor strength. For them, the  likelihood of incontinence and the discomfort of pelvic prolapse  developing later in life are more common. 

The actual specific risks of developing incontinence vary for  individual women.  Each woman is unique; some heal more quickly than  others or the inborn strength of one person's tissues may be different  from the strength of another's.  However, the likelihood of permanent  nerve damage does increase with the number of babies you deliver, as the  tissues tend not to heal as well with each subsequent injury.  Size  probably matters too, although not all studies have found this to be  factor.  However, it makes sense that the bigger the baby, or the  smaller the pelvic bones, the more pressure is exerted on the pelvic  muscles and nerves.  Right now, there is not an accurate enough way to  estimate the size of a baby or the size of the pelvic bones to warrant  inducing labor before a baby is thought to be too big for the mother. We  all probably know small women who have easily delivered large babies.   Ultrasound can measure the size of the baby's head somewhat accurately,  but it is unable to tell the size of the pelvis or how flexible the  pelvis will be during labor.  Therefore, obstetricians are generally  unable to predict which labor will be difficult and which easy. 
         
         


         Labor and delivery may stretch, strain or even tear the muscles  and the supporting tissues that hold the uterus, bladder and rectum in  their proper place. The nerves may also be stretched and injured,  weakening the signals allowing muscles to work properly. Some women have  no damage from labor and delivery, some have damage to the nerves; some  have damage to the muscles and supporting ligaments; some have damage  to every one of these areas. 

If injury results from a delivery, the weakened support of  the bladder, rectum or uterus may cause dropping of these organs into  the vagina. Dropping of any of these organs is called pelvic relaxation,  or prolapse. The muscles and supporting tissues that are above the  vagina and that hold the bladder up are weakened or torn, allowing the  bladder to drop down into the vagina.  This bulging of the bladder into  the vagina is called bladder prolapse, or a cystocele (see fig XX).  The  urethra, the tube that you urinate from, can also drop down.   This  combination of the changes in the normal position of the bladder and  urethra and the weakened nerve signals may interfere with the bladder  function with resulting urine leakage. 
         
         

CAN KEGEL EXERCISES DURING PREGNANCY PREVENT INCONTINENCE?


         Kegel exercises, fully described in chapter 9, help to  strengthen the muscles in the pelvis. Exercising these muscles during  pregnancy has been shown to decrease incontinence during pregnancy and  right after delivery. A recent study evaluated two groups of women for  incontinence 10 months after delivery. One group had pelvic floor muscle  training using a combination of Kegel exercises taught by biofeedback  and mild electrical stimulation to contract the pelvic muscles (see  chapter x) twice a week for 6 weeks. The other group had no such  training.  Twenty percent of the women who had pelvic floor training  showed a decrease in incontinence 10 months later compared to only 2% of  women who did not have the training.    However, we still do not know  if theses exercises will prevent the development of incontinence for the  many years that follow. 

CAN CHILDBIRTH LEAD TO ANAL INCONTINENCE?


         The muscles that lie directly below the vagina and encircle the  rectum are the muscles that control bowel movements.  During the final  phases of labor, pushing the baby through the vagina to delivery, these  muscles are subjected to enormous forces and pressures. As a result,  injury may occur. Just as for urinary incontinence, there is a higher  likelihood of anal incontinence for a woman following a vaginal delivery  than following a cesarean section.  Studies show that more than a third  of women who deliver vaginally have some damage to these anal muscles.   In women with a forceps delivery, about 80% have damage to the anal  muscles.  Injured nerves can also be found in these women.  Most recover  their pre-labor function, but for some the damaging effects can persist  for years. The result of severe injury to anal muscles and nerves can  be the inability of the anal muscle to close entirely with resultant  involuntary loss of gas or stool. 

Despite the obstetricians' efforts to repair any obvious  tears right after vaginal delivery, they only repair what they can see,  the outside anal muscle.  However, much of the damage may be done to  other anal muscles, higher up in the rectum and not easily seen by the  doctor. About one-third of women have this damage. In addition, if the  muscle is injured, the harm may be under normal appearing skin (called  an occult, or hidden, injury) and may not be visible to the doctor at  all. Since most of the control of holding stool resides in these anal  muscles, failure to repair them can lead to incontinence of stool or gas  (see chapter 11).  Even after repair, a few women still experience some  degree of incontinence of stool or gas.  However, some women who have  incomplete healing of the anal muscles do not have anal incontinence, so  there must be other factors involved.  Traditional methods of repair of  these muscles taught to obstetricians are occasionally inadequate.  We  hope with further study of how these muscles are injured, new techniques  for repair will help avoid incontinence. 
         
         

CAN EPISIOTOMY LEAD TO ANAL INCONTINENCE?


         Just before the delivery of the baby's head, an incision may be  made by the doctor in the skin and, sometimes, also in the muscle at the  bottom portion of the vagina to allow more room for the baby to  deliver.  This incision, called (midline) episiotomy, is supposed to  avoid incidental tearing of the vagina or rectum as the baby delivers.   Episiotomy is a recent practice, devised in order to substitute a  straight, clean, easy-to-repair surgical incision for the jagged tear  that might otherwise occur. Cutting this incision is also intended to  shorten labor by giving the baby's head more room so delivery might be  easier and faster.  It was thought that faster delivery would decrease  the risk of injury to the mother's bladder, and would be gentler for the  baby's head.  However, studies show no evidence that these assumptions  are true. 

Much to everyone's surprise, episiotomy may actually cause,  not prevent, pelvic prolapse and incontinence, exactly what it was  supposed to help avoid. Cutting through the vaginal skin weakens this  area and increases the likelihood that the skin will rip further down,  possibly tearing into the anal muscle directly below the vagina.    If  the skin stretches naturally, it is less likely to split apart, and if  it does tear, the tear is likely to be shorter.   Studies tell us  episiotomy may actually lead to more damage of the anal muscles. If  injury occurs, control of the anal muscles may be partially lost, and  incontinence of gas or stool may result.  For these reasons, it is  probably best not to have a routine episiotomy at the time of delivery.  Women need to discuss episiotomy with their doctors before the baby is  due.   More about anal incontinence can be found in chapter 11.
         
         

DOES CESAREAN SECTION PROTECT AGAINST PROLAPSE AND INCONTINENCE?


         Because cesarean section avoids the stretching and tearing of  the muscles and nerves that occurs as the baby's head comes through the  pelvis, it makes some sense that women who have a cesarean section might  have less of a risk of urinary incontinence, anal incontinence and  pelvic prolapse.  In fact, a few studies show just that.  However, most  women who deliver vaginally remain continent, so no one is proposing  that all women have cesarean sections in order to avoid the possibility  of later incontinence.  We clearly do not understand all the factors  that determine who develops incontinence, so cesarean section would not  be necessary in many women with long or difficult labors.  With our  present understanding, many women would have to have cesareans in order  to prevent one woman from developing incontinence. In addition, cesarean  section has its own risks including bleeding and possible need for  transfusion, possibility of infection, risks of anesthesia and the risk  of surgical injury to the bladder or intestines.  The prolonged  discomfort and recovery from cesarean at a time when the mother wants to  be focused on caring for her baby are also not in anyone's best  interest. 

Some studies regarding deliveries and bladder health find a  number of factors that might increase the risk of developing  incontinence or prolapse.  These studies are based on a small sample (a  relatively small number of women), and the results show somewhat  differing risk factors.  However, from these studies we know that a  large baby, a mother with small pelvic bones, a prolonged labor, a baby  whose head is in the wrong position during labor, or the use of forceps  can be associated with the later development of incontinence. As further  research continues to shed light on factors that contribute to  incontinence, women should consider discussing potential risk factors  with their obstetricians before or during labor. Multiple risk factors  might convince a woman and her physician to choose a cesarean section  rather than a vaginal delivery.  Interestingly, a survey found that 31%  of female obstetricians would prefer a cesarean section even if there  were no problems with their pregnancy or labor. Eighty percent of these  female doctors say they would make this choice in order to protect  themselves from the possible development of incontinence or prolapse.   Because the research is still not entirely clear, the subject of  preventative cesarean section is controversial, to say the least.  Only  further research will determine whether obstetricians need to change the  advice we give women about labor, vaginal delivery and cesarean  section. 
         
         

CAN ANYTHING BE DONE TO PREVENT INCONTINENCE THAT RESULTS FROM CHILDBIRTH?


         No one is advocating that women have babies only by cesarean  section.  While many women show evidence of injury to the muscles and  nerves in the pelvis after delivery, most of the changes heal, and most  women do not go on to develop incontinence.  Other factors, including  the inborn strength of your body's tissues, contribute to the risk of  incontinence.  We do not yet know enough to predict exactly which women  are at risk and, therefore, which women would benefit from cesarean  section.  However, there are some things that might be avoided in order  to decrease the likelihood that pelvic injury will occur. 

·	Allowing the contractions of the uterus alone to push the  baby down the birth canal, without having the mother push, has been  shown to decrease the risk of injury to the nerves and muscles of the  pelvis. Having the mother push the baby down the birth canal is often  encouraged as soon as the cervix is fully dilated. Words of  encouragement to "push, push, push" are heard from Lamaze classes and  labor rooms everywhere.  It appears that this may not be the best  advice.  Patience instead of pushing at this time may decrease the risk  of developing incontinence. Pushing can just be saved for the delivery  of the baby's head.
           
           ·	Although doctors now cut episiotomies in more than half of  all vaginal deliveries, this practice should be discouraged.  Because  episiotomies increase, rather than decrease, the risk of damage to the  anal muscles, the baby's head should be allowed to come out naturally.   As the baby's head descends, massage of the area between the vagina and  the rectum, called the perineum, may help gently stretch and soften the  skin and underlying muscles and prevent tearing. If a tear occurs  naturally, it is less likely to go through the anal muscles.  In the  future, as improved techniques are developed, doctors may be able to  repair muscles higher in the anal canal, with better results. 
           
           ·	Proper positioning of the mother and excellent lighting are  important for the doctor to achieve the best possible repair of injured  tissues and muscles. While giving birth in a birthing room is a  wonderful experience, the birthing room may not be the best place to  repair injuries to the vaginal muscles. Sometimes that requires moving  to a delivery room or operating room.  Proper repair should increase the  strength of these tissues and muscles and decrease the risk of future  incontinence and prolapse. 

·	The use of forceps should be discouraged. Substantial,  documented evidence shows the use of forceps increases the risk of  injury to the nerves and muscles of the pelvis, much of which is  irreversible. 

·	A much more liberal approach to the use of cesarean  section for women who have a large baby, small pelvic bones, a baby  whose head is in the wrong position, or who have a prolonged labor may  help to avoid damage to the mother. For years, obstetricians focused  only on the outcome of the health of the baby at the time of delivery.  Without question, this should still be their absolute priority. However,  as women live longer and healthier lives, we cannot ignore the impact  of difficult labors and deliveries on their quality of life as well.  Shortsighted obstetrical practices that ignore these long-term problems  are not in the best interest of women's health.  Many women have been  encouraged by doctors, nurses, childbirth educators, even friends and  family to endure prolonged labors and difficult deliveries in order to  have "natural" births.  Most of these women are not aware of the  potential risks that prolonged labor or difficult deliveries can pose to  their future health and comfort.

Until recently, studies were not available for women and  their doctors to show that these risks, in fact, existed.  With the  development of the subspecialty of urogynecology, a field of doctors  specifically trained to deal with female incontinence and prolapse, more  of this research is being performed and more widely published.  As is  often true, it may take years for the full effects of these findings to  influence actual obstetric practice. 

It may be best for women and their doctors to discuss these  issues before labor and delivery and to come to some agreement as to the  reasonable choices if a prolonged labor or difficult labor is  encountered. Some women may choose to avoid cesarean section at all  costs, while others may opt for earlier cesarean section. However, it is  time for these conversations to take place.  As a patient, each woman  can act as both a consumer and advocate for her own health.  Being armed  with information and having the courage to question will go a long way  to help you get the best care possible.

Allen R, Hosker G, Smith A, Warrell D. Pelvic floor damage and childbirth: a neurophysiologic study. 1990 British Journal of Obstetrics and Gynecology 97;770.

Chiaffarino F, Chatenoud L, Dindelli M, et al. 1999. Reproductive Factors, family history, occupation and risk of urogenital prolapse. European Journal of Obstetrics and Gynecology and Reproductive Biology 82;63.

Connolly A, Thorp J. 1999. Childbirth-related perineal trauma: Clinical significance and prevention. Clinical Obstetrics and Gynecology 42;820.

Handa V, Harris T, Ostergard D. 1996. Protecting the pelvic floor: Obstetric management to prevent incontinence and pelvic organ prolapse. Obstetrics and Gynecology 88;470.

Meyer S, Hohlfeld P, Achtari C, et al. 2000. Birth trauma: short and long term effects of forceps delivery compared with spontaneous delivery on various pelvic floor parameters. British Journal of Obstetrics and Gynecology 107;1360.

Meyer S, Hohlfeld P, Achtari C, De Grandi P. 2001. Pelvic floor education after vagianl delivery. Obstetrics and Gynecology 97;673.

Norton P. Pelvic floor disorders: the role of fascia and ligaments. 1993. Clinical Obstetrics and Gynecology 36;926.

Snooks S, Swash M, Mathers S, Henry M. 1990. Effect of vaginal delivery on the pelvic floor: a 5-year follow-up. British Journal of Surgery 77;1358.

Sultan A, Stanton S. 1996. Preserving the pelvic floor and perineum during childbirth- elective cesarean section? British Journal of Obstetrics and Gynecology 103;731.

Everyone who has had a child knows that once a baby is born, life is never the same again.

Rachel L. Parker

Articles

The Incontinence Solution: Answers for Women of All Ages

Excerpts from The Incontinence Solution: Answers for Women of All Ages