Q&A: getting back to normal "down there"

A reader writes:

"I have read your preventing PPD posts with interest, but I noticed you didn't mention the physical toll of giving birth. I wound up with a cystocele after giving birth (3 hours of pushing plus forceps), and while pelvic floor therapy has helped somewhat, things are still not right. The Today sponge came back on the market but I can't use it because it won't stay where it's supposed to. Sex was excruciatingly painful at first and is less so after the PFT, but sometimes afterward it feels like everything is going to fall out. I have felt like giving birth damaged me irreparably and it's hard to imagine going through it again. So I guess I'm wondering, does everyone feel like this? Does this feeling go away?

Another question is, I have seen you heartily recommend Kegels in comments on other people's blogs, and I wondered if you would care to elaborate. How many should I be doing? What kind? How often? Most importantly, how on earth do you remember to do them?"

This reader's question sounds like her damage from pushing was more serious than most women experience. From what I know from hanging out in playgroups and the internet, most of us are back up and feeling pretty normal down there again within a couple of weeks or months. (Or days, for second or subsequent children, for some of us.) Whether or not we feel like having sex because of the touch issues and all that postpartum stuff, and whether or not we're having issues with lubrication, most of us have regained (or are Kegeling our ways to regaining) pelvic floor integrity.

I guess I figure a good common-sense test about whether healing is happening normally would be to judge things the same way you did when you were having nipple pain during the first few days of nursing: If it makes you suck in your breath and curse a little at first, it's normal, and should get progressively better. (And you should use Astroglide or another good lubricant.) If it makes you want to cry, it's not, and you should get some expert help.

Now why this damage happens to some women is a whole big issue. I think there are some women who have fast births ("precipitous births"), in which the baby kind of whooshes out of them faster than their bodies can open up all the way for. But I think a lot of damage to the woman's body is caused by birthing practices in Western hospitals, and could be avoided if more emphasis was placed on the mother's health and less on speeding labor and delivery along as fast as possible. A generation ago, the problem for women was having a forceps birth with a huge episiotomy. Now forceps aren't so much in vogue, but it's become the standard (a standard based on going against the evidence, I might add) to strap women to the external fetal monitor the second they walk into the hospital. This means that a woman is laboring on her back for most of her labor, and gravity isn't helping to move the baby down. When it's time to push, she's often starting pushing with the baby way up in her pelvis, so she pushes long and hard for hours. That much sustained stress is bound to cause some damage.

I've also noticed a new trend of having women "push themselves dilated," meaning that they're told to start pushing at 8 or 9 cm to try to "help open them up." A friend of mine was told to start pushing at 7 cm! I cannot imagine the rationale for this, since the danger of bruising and swelling of the cervix is strong. Even if it eventually works (my friend pushed for 4 hours, then was told she "wasn't a good pusher" and given an emergency c-section), it's causing unnecessary damage to the mother.

If I could intitute widespread change to improve the health of women's pelvic floors, I'd fully staff L&D floors so there were enough nurses to perform manual heartrate monitoring every 10 minutes (which gives the same fetal and maternal health outcomes as continuous external monitoring does, but without the collateral damage), do away with continuous external fetal monitors for all but high-risk mothers, encourage walking epidurals and have the mothers be up and using gravity until it was time to push, and conduct pushing on birthing stools instead of in the lithotomy position. There are all sorts of ways to modify things so women's bodies don't get damaged from childbirth. The reason we don't do them is that they don't help hospitals make money, and we aren't demanding them.

But back to the issue at hand--what to do now. I called in a guest, who had the same issues as our questioner. She ended up getting surgery to correct the problem (after also trying pelvic floor physical therapy, which is something I never even knew existed). She sent me the following comments:

"The more I learn about the "traditional" method of treating prolapse issues, the more vocal I am becoming about women demanding the type of surgery I had done.  Unfortunately, as it is a fairly new procedure, there aren't many doctors certified to do it but the results are worth all the effort to locate one.

For starters, I would recommend your reader get in touch with a urogynecologist through www.augs.org. They are specialists who have spent extra time learning about how all the girlie-bits fit together with the other organs in the pelvis. It's a fairly new specialty and has only come of age in the past 5-7 years as women are demanding better and more effective solutions to pelvic floor disorders.  The surgery I had done is called a Gynecare Prolift, where Gortex mesh is inserted to help support vaginal walls (Johnson & Johnson is the manufacturer of the mesh). This surgery has been done in Europe for several years with excellent success and was only introduced in the US in March of 2005.  Consequently, doctors who are certified to perform this surgery are even fewer and further between here in the states.  Knowing what I know now, I would drive/travel whatever distance to have the surgery performed by a qualified urogynecologist.  The very next morning after surgery,  I woke up and could tell "things" were different--anyone who has had prolapse issues knows just what I am talking about.  For the first time in years, it didn't feel like things were...falling."

If you're in pain and discomfort from pelvic floor damage or prolapsed uterus, don't suffer in silence. Seek out a urogynecologist and get help. You're not damaged forever.

Now, for those of us who just need to get the tone back after using the amazing vagina to push out a baby, or for those of you who had c-sections but are leaking urine just from having been pregnant, it's time for Kegels. The vagina is just like any other muscle in the body--the more you use it, the stronger it gets. So to get tone back in your lady business or to stop leaking when you cough, do Kegels. Here's a good summary of Kegels. My favorite is the "elevator Kegel." Start tightening a little more in defined bursts, like you're moving your pelvic floor up up up like an elevator. Then move it down down down floor by floor to release. These are going to rebuild the muscle fibers in one direction. To rebuild in the other direction, do a bunch of smooth hard squeezes (just like you do when you cough).

The best time to do Kegels is as soon as you deliver your baby (doing them immediately postpartum will help you heal, even if you have stitches). I tried to do them for a few minutes whenever I was sitting down to feed the baby for the first few months. (Like you need another thing to remember. But you might as well be doing something for yourself while you're sitting there feeding your child. Just don't squeeze away during the whole feeding session or you could give yourself a sore muscle.) Now, a year out, I just do them while I brush my teeth. It's a couple of minutes a few times a day, but it makes such a difference.

If anyone wants to offer data points, feel free to comment anonymously (stick a fake URL in the URL box) or email me privately.