We need to speak more honestly about the risks of childbirth. Vaginal birth can lead to a lifetime of serious, embarrassing and life altering problems. Uterine prolapse, with or without incontinence, is an entirely natural consequence of an entirely natural vaginal birth.
What is uterine prolapse? As the animation above demonstrates, uterine prolapse is when the uterus falls down the vagina. It is described in terms of degrees. The animation shows a grade 3 prolapse where the cervix hangs out the vagina but the rest of the uterus stays inside.
To understand why these problems develop we need to understand how the pelvic organs are held in place. Why doesn’t the uterus fall down through the vagina before childbirth? It’s partly because of ligaments that hold it in place in the pelvis, but it’s mostly because of the muscles of the pelvic floor form a sling to hold the organs up.
Multiple muscles form a sling perforated by three tubes: the urethra, which carries urine from the bladder to the outside, the vagina, and the rectum.
Imagine a baby’s head, 10 centimeters in diameter, passing through this sling. It’s obvious that the fetal head is going to dramatically stretch, distort and possibly tear the muscles that surround the vagina. They will literally never be the same again. Where once the space between the muscles of the pelvic floor was only large enough to accommodate three relatively small tubes, now that space has been stretched tremendously.
Keep in mind that we are talking about internal muscles, not the tears in the vagina that occur externally (1st, 2nd, 3rd and 4th degree tears). External tears produce visible external damage. Internal injuries to muscles do not.
The most common injury to these muscles is stretching and kegel exercises are designed to strengthen the muscles and thereby tighten them. But the injuries can be more severe than stretching. The muscles themselves can be torn away from the pelvic bones.
No amount of kegel exercises can repair pelvic muscles that are torn. When these muscles are torn, the uterus can slip through the middle of the pelvic floor. This is uterine prolapse.
The damage to the internal muscles may not be immediately apparent. It may not become obvious until menopause when ligaments are weakened by the lack of estrogen and the uterus begin to drop between the muscles. A woman who has had no problem for 20+ years after the births of her children may gradually develop uterine prolapse and/or incontinence as she enters menopause.
When the uterus prolapses it can cause a feeling of heaviness or fullness, bulging in the vagina, lower-back pain and painful intercourse.
When the uterus prolapses, it can distort the relationship between the sphincter that controls release of urine from the bladder into the urethra. Although the sphincter itself has not been damaged, it nonetheless prevents the woman from “holding” urine. The sphincter works well enough that urine doesn’t constantly dribble out of the urethra, but when the intra-abdominal pressure is dramatically increased as occurs during coughing and sneezing, urine squirts out (stress urinary incontinence).
How often does damage to the pelvic floor occur? Research suggests that up to 75% of women who have a vaginal birth will end up with some permanent damage to the muscles. The likelihood of damage rises dramatically with the use of forceps for obvious reasons. Putting forceps into the vagina and around the baby’s head creates a larger diameter than the baby’s head alone.
Uterine prolapse and its associated symptoms like painful sex and incontinence are not trivial problems. They can be life altering and it’s hardly surprising that many women want to avoid them by having a maternal request C-section.
It’s deeply unfortunate that in a society like ours, where vaginal birth is valued more than C-sections, no one warns women that eventual uterine prolapse and urinary incontinence can occur as a result of vaginal birth.
