Category — Body After Baby

Cesarean on Demand

More women than ever before are showing up at the hospital in labor and asking for a cesarean section.

According to the National Institutes of Health, the rate of c-section delivery has increased 40% since the mid-90s, a trend reflected in these NIH summary statements:

Between 1996 and 2007, the C-section rate rose by 53 percent, with similar rises seen among all age, racial and ethnic groups, according to the report released Tuesday from the U.S. Centers for Disease Control and Prevention’s National Center for Health Statistics, which used birth certificate data to arrive at this conclusion.

and:

After a slight dip in the late 1990s, C-section rates began marching relentlessly upward again. The pace of the increase has accelerated since 2000, with the overall rate surging from 23 percent to 32 percent in 2007

That translates to about one in four American babies being born via cesarean section.

So why has “cesarean on demand” become so popular?

One frequent reason is today’s mom-to-be believes avoiding a vaginal birth will reduce her risk of incontinence and pelvic organ prolapse down the road.

Pelvic organ prolapse is a condition that occurs when a woman’s bladder, rectum, or uterus shifts from its proper location, and moves into the vaginal canal.

But giving birth via cesarean section is NOT NECESSARILY the 100% protection from protection that some women think it is.

If only we came with zippers

Pelvic Organ Prolapse and Pregnancy

There’s new research on this topic, reflected in a new study published in the International Urogynecology Journal that examined the impact of a woman’s first pregnancy on pelvic support and found that less than one year after giving birth via c-section without labor, 21% of women experienced moderate organ prolapse and 5% of women who had cesarean deliveries experienced severe prolapse.

Since cesarean delivery did not necessarily prevent prolapse, the study’s authors suggest that simply BEING PREGNANT can increase a woman’s likelihood of prolapse, regardless of delivery mode!

This coincides with data showing that 50% of women who have borne children will experience prolapse at some point,  compared with 30% of ALL women, including women who’ve never been pregnant.

It IS important to note that women who gave birth vaginally DID experience higher rates of prolapse, according to the same Urogynecology Journal study.

But are these numbers significant enough to warrant cesarean on demand?

Maternal and neonatal mortality, uterine rupture, placenta previa & obstetric hemorrhage

Maternal mortality rates from cesarean are THREE TIMES higher than in vaginal delivery, according to Obstetrics and Gynecology.

Moreover, Birth magazine reported that babies are more than twice as likely to die when delivered via cesarean.

Knowing this, it makes sense NOT to opt for c-section delivery unless there is a legitimate medical reason for the best health of the mother or the baby.

Once the uterus heals from cesarean, future pregnancies are at risk for uterine scar separation, called uterine rupture, that can be deadly for the baby, and for problems with placenta previa, where the placenta is low and can hemorrhage at any time, further risking the life of the baby. Uterine rupture and obstetric hemorrhage are two good reasons to take cesarean section very seriously.

Thinking about elective cesarean section? Be a smart mother – make a wise choice with your obstetrician.

For a video on this topic, visit HealthGuru.com video on the truth about childbearing and cesarean on demand

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org

Understanding Rectocele, Levatorplasty and Site-specific Rectocele surgery techniques

You may be unacquainted with the term “rectocele,” but for almost 19% of women, the condition is all too familiar!

In a normal female pelvis, the rectum rests behind the vagina.

The two are separated by a thin wall of fibrous tissue called fascia.

When the fascia becomes weakened or damaged, the front of the rectum can bulge into the vagina. This is known as rectocele.

Rectocele - how it looks to the patient

Pregnancies and childbirth, chronic constipation and the natural aging process are the most common causes, but other factors can contribute to weakening of the fascia, too, including: chronic cough or bronchitis, repeated heavy lifting, and being overweight or obese.

Whatever the cause, rectoceles may induce a sensation of rectal pressure or fullness.

Difficulty having bowel movements and a feeling that the rectum has not fully emptied afterward are also common.

Severe rectoceles may even become visible, appearing as a ballooning bulge protruding through the vaginal opening.

For more mild cases of rectocele, a vaginal pessary may effectively treat the problem. Pessaries are removable supportive devices that hold the rectum in place.

More often than not, though, treatment for a severe rectocele requires surgery, performed through a small incision in the back wall of the vagina. .

The most common type of rectocele surgery is a levatorplasty, using sutures to bring the inside edges of the levator ani, or Kegel, muscles closer together, reducing the rectocele bulge back to a normal contour.

This method works because the levator muscles support the entire pelvic floor like a sling, and they’re often pulled apart with rectocele.

Some specialists believe, and some clinical research shows, that levatorplasty rectocele surgery may be more likely to result in pain than other rectocele repair techniques.

Knowing this, some doctors choose to do a newer procedure called site-specific rectocele, which uses sutures to close ONLY the holes in the connective fascia tissue, bypassing the levator muscles completely.

Although LESS likely to cause pain, site-specific rectocele techniques are MORE likely to result in recurrence of the rectocele.

Because each procedure has its good and bad points, it’s important to discuss the best rectocele repair for YOU with your surgeon.

For more information, see this video on Understanding Rectocele, courtesy HealthGuru.com

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

KEGEL EXERCISE: THE FACTS

If you have a vagina and you’re old enough to vote, then Kegel Exercise belongs in your feminine fitness daily routine. Before you dive into pelvic fitness, it’s important to know what Kegel muscles actually DO. Kegels—or the levator ani muscles—wrap around a woman’s most important parts: her bladder, vagina, and rectum.

Research shows that toned levator ani muscles can reduce urinary incontinence, prevent problems with vaginal laxity and help a woman achieve a stronger orgasm. Clinicians and researchers in urogynecology also suspect, but have yet to prove, that these muscles help prevent pelvic organ prolapse, a condition in which  a woman’s bladder, rectum, or uterus falls into her vagina.

For women looking to live their best lives, strengthening your Kegel muscles—or pelvic floor fitness—just makes sense!

HOW TO CHECK YOUR KEGEL EXERCISE ACCURACY:

To get started, sit in bed relaxed against pillows, knees up and separated, using a hand mirror to look at your perineum,which is the skin between your anus and vagina.

Pull in using the muscles you use to urinate, as if you’re trying to stop urine midstream.

If you’re Kegeling correctly, you’ll see your perineum retract into your body.

You should feel the pull in your urethra and anus, NOT your butt or abs.

If you have trouble with proper Kegeling, talk to your gynecologist about pelvic floor physical therapy.

Pelvic floor physical therapy involves working with a Kegel coach, using biofeedback, and/or pelvic muscle electrical stimulation, each designed to “train” your pelvic muscles to perform correctly.

Once you’ve got the art of Kegeling down, get in the habit of doing tKegels daily.

Here’s Dr. Romanzi’s “Starter Set for Kegel Beginners”:

For the first set, perform 10 controlled, sustained contractions, holding each for five seconds, relaxing out of each slowly, and contracting into the next one without taking a break in between. Don’t forget to BREATH. If you find yourself holding your  breath, count softly or sing while contracting the levator muscles.

For the second set, perform 30 quick contractions, holding for just one second each.

There’s no need for a break between the two sets. Simply move from one right on to the next.

Do 2-3 of each set per day. Be creative! There are many ways and settings in which one can Kegel – no one will know if you’re Kegeling on the bus or in a meeting or while driving your car (at a stop sign, preferably).

In terms of where you should do your Kegel exercises, there’s only one rule: NEVER do them on the toilet!

Not only is 8 seconds of urination too short to really benefit your muscles, but it’s also distracting to your bladder, which has an important job of its own to do!

Other than that, you can fit in a Kegel routine whenever—and wherever—you prefer!

For more information, check out this  video \”Kegel Exercise: The Facts\”, courtesy HealthGuru.com

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

DROPPED BLADDER: CYSTOCELE FACTS

Image of the Bladder on X-Ray

At birth, a female’s bladder rests in front of her vagina and just behind the pubic bone. The bladder and vagina are separated by connective tissue called the vesicovaginal fascia. This fascia is anchored to each hip bone by tendons known as the arcus tendineus fascia pelvis.

Vesicovaginal connective tissue is NOT particularly strong. Even in a young woman who has never given birth, the tissue layer is only about as thick as five sheets of paper! When a woman gives birth, the vesicovaginal fascia can weaken and stretch. Other factors that can contribute to the weakening of this and other pelvic supportive tissue include: being overweight or obese, engaging in recurrent heavy lifting, the normal aging process, and repeated coughing or constipation.

Weakened vesicovaginal connective tissue may result in a vaginal hernia that allows the bladder to drop, a condition called cystocele. If the vesicovaginal space wears out in the center, the bladder may bulge into the vagina in what’s called a CENTRAL cystocele. Meanwhile, if the tissue disconnects from the arcus tendineus inside the hip bones on either side, the result is a PARAVAGINAL cystocele.

Cystocele Symptoms

But no matter the type, cystocele can cause unpleasant symptoms, like a vaginal bulge coming out between the labia, or make urinary incontinence worse, or prevent the bladder from emptying fully. Women may also experience chronic pressure in the pelvis or vagina that may be worse when coughing, bearing down, or lifting. Severe cystoceles may even emerge through the vaginal opening, causing a soft bulge that may feel like sitting on an egg.

Cystocele Treatment

While it can be uncomfortable and embarrassing, treatment options DO exist to repair cystocele, or dropped bladder . In mild cases, a removable support device called a pessary can push the bladder back into place. More severe cystoceles may require surgery. Traditionally, bladder lift surgery involved tucking stitches into the remnants of the supportive tissue between the bladder and the vagina during a procedure called anterior colporrhaphy.

This surgery has a recurrence risk as high as 30%, so many surgeons may prefer to insert a graft, which is a thin sheet of body-friendly material, as extra support between the bladder and the vagina. The trade-off for the graft’s sturdier hold is a slightly higher risk of complications including prolonged healing inside of the vagina and slightly longer time on the operating table. The recurrence rate of cystocele repaired with graft material is much lower than traditional colporrhaphy repairs.

Because each procedure has its pros and cons, talk to your doctor about the best repair option for YOU!

For more information on cystocele, visit Cystocele and Pelvic Organ Prolapse information and see this video on Understanding Cystocele, courtesy HealthGuru.com

Content herein does not represent medical advice. To learn more about pelvic floor disorders such as fistula, pelvic organ prolapse, dropped bladder, dropped uterus, hysteropexy uterine resuspension, vaginal laxity, rectocele, postpartum rehabilitation, vaginal rejuvenation, labiaplasty, vaginoplasty, Kegel exercise or incontinence please visit other posts in this blog and the Urogynics website at www.urogynics.org.

Worldwide, “cesarean on demand” continues to increase. In the hopes of avoiding pelvic floor damage associated with birthing, some women have bought into the the trend for elective cesarean before onset of labor. Called “cesarean on demand” because patients demand it in the absence of a maternal or fetal indication, it’s the obstetric equivalent of Erica Jong’s “Zipless F**k”; the maternity version of having your cake and eating it too.

Well, guess what? Just BEING PREGNANT is a risk for all the unhappiness that pelvic floor mayhem can bring, including incontinence and its painfully un-sexy cousin, pelvic organ prolapse. One beautifully executed study evaluated vaginal anatomy before and after 1st pregnancy in three groups of mothers; one who had an easy vaginal birth, another who had a difficult vaginal birth with deep vaginal tearing that required lots of stitching, and third who, whatever the reason, had cesarean before going into labor. Understand that there are medically legitimate reasons for a woman to have cesarean without labor, such as toxemia (pregnancy induced high blood pressure), placenta previa (low-lying placenta blocking the cervix – natural labor with this condition results in the baby bleeding to death before it can be born), or breech presentation (at least in the States, due to out of control obstetric malpractice and the fact that breeches born vaginally have a small but real risk of birth injury that can be almost totally avoided with a cesarean, breech = cesarean until further notice), to name a few.

Looking at the pelvic floor support of these women after first birth, they found NO DIFFERENCE in moderate prolapse between the three groups. Severe prolapse was equivalent in the two vaginal birth groups and much higher than in the cesarean without labor group. But… the cesarean without labor group had a 5% incidence of severe prolapse – I’m talking cervix sticking out of the vagina prolapse, bladder bulging down pushing the labia apart when you walk prolapse.  Thinking a cesarean is the answer to your “I want to be a mother but I don’t want any physical changes in my body anywhere, especially in my vagina” dreams? Think again…

Here’s the study summary prepared for the Journal of Sexual Medicine:

Handa VL, Nygaard I, Kenton K, Cundiff GW, Ghetti C, Ye W, Richter HE. Pelvic organ support among women in the first year after childbirth. Int Urogynecol J (2009)1407-1411.

Increased public awareness of changes in pelvic floor anatomy related to pregnancy continues to foster the growing phenomenon of cesarean on demand, requested in the hopes of maintaining pre-pregnancy sexual function and reducing risk of prolapse and incontinence, two conditions known to negatively impact sexual quality of life in the majority of women so-affected. The true impact of pregnancy on pelvic support may be due to pregnancy itself, regardless of delivery mode, as stated by these authors; “cesarean delivery as a potential prevention strategy remains unproven.” This study prospectively evaluated the impact of first pregnancy on pelvic organ support of 256 women with three pregnancy outcomes – vaginal delivery without anal sphincter tear, vaginal delivery with anal sphincter tear, and cesarean delivery without labor. Pelvic support evaluation done at 6-12 month post-delivery showed stage 2 prolapse in 38% of women delivered vaginally with sphincter tear, 29% in those delivered vaginally without sphincter tear, and in 21% of women delivered by no-labor cesarean with no statistically significant differences between groups.  It is remarkable that 1/5 of the cesarean patients showed clinically significant stage 2 prolapse.  When looking further at stage 3 (true bulging past the hymen, clearly visible and palpable through the vaginal opening), there was a significant difference between vaginal birth and cesarean without labor, with 5% of cesarean women showing visible prolapse as opposed to 14-15% in both of the vaginal delivery groups.  Still, this 5% bulging prolapse despite non-labor cesarean raises the possibility that optimal patient counseling for women seeking elective cesarean for sexual function and pelvic organ protection may best include the realistic prediction of “a small but real risk bad prolapse even if you undergo cesarean before going into labor”. Letting women know that cesarean is NOT a 100% guarantee of avoiding pelvic floor consequences of pregnancy, along with the other risks of cesarean: peri-op morbidity, increased risk of placenta accreta, and increased risk of uterine rupture with subsequent pregnancies. This work adds to the data revealing that the impact of pregnancy on the pelvic floor may not be thoroughly negated by cesarean on demand.

Level of Evidence: IA

(c) 2010 Lauri Romanzi