Don't Ignore the Realities of Pelvic Trauma From Childbirth

Jocelyn J. Fitzgerald, MD


July 20, 2022

Birth and its aftermath are wildly complex topics biologically, socially, and ethically. Nothing in men's health compares.

Despite their complexity, shame and discomfort with female bodies generally has led to a constant oversimplification and softening of the realities of the birth process. Pregnancy is deeply gendered in society and medicine alike, and we struggle to balance the autonomy of the pregnant patient with the often-emergent nature of pregnancy and delivery gone awry.

Any process that requires incalculable steps to produce a "perfect" outcome is going to fail a significant amount of the time; for the health of our society, we must acknowledge this fact. Creating a realistic discourse about birth that both honors and empowers the pregnant patient while also acknowledging that the immense process of personally building and delivering a new human into the world brings with it umpteen opportunities for maternal trauma.

This level of responsibility requires open discussion about the real risks and benefits of childbearing. The burden is even greater and more urgent in light of the US Supreme Court's recent decision overturning Roe v Wade — a ruling that will force many women and girls to deliver at term against their will.

As a urogynecologist and pelvic reconstructive surgeon, I know all too well that there are harmful attitudes — even among my obstetrician colleagues — that keep my patients in the dark about injuries to the pelvic floor that can result from childbirth. These misconceptions lead to a "we'll deal with it later" damage control approach that often leaves patients feeling betrayed and powerless.

Research has shown that educating patients about pelvic floor trauma before pregnancy or delivery reduces, not increases, their anxiety about developing a pelvic floor disorder because they feel prepared. Ultimately, patients can do whatever they want with the facts, and it is never our job as clinicians to withhold information from patients because of our fears of how they will use it.

So what are the facts about maternal postpartum pelvic floor disorders? And what are pelvic floor disorders?

Even with the impressive tissue remodeling that pregnancy causes in the female body, it would be preposterous to think that the expulsion of a full-term fetus through a small complex neuromuscular structure containing the bladder and rectum doesn't stretch, crush, or cause blunt trauma to the area, no matter how "natural" of a process birth is purported to be. The result is a rogues gallery of physical consequences: bladder dysfunction; anal sphincter tears; levator avulsions, in which the levator ani muscles tear off of the pubic bones; altered sexual response and sensation; an increased risk for vaginal prolapse — when the vagina and pelvic organs fall out of position — and urinary and fecal incontinence.

Of course, in many deliveries, the best outcomes align with minimal intervention, which is a beautiful thing. But larger babies, prolonged pushing, operative delivery with vacuum and forceps, and perineal and rectal tears all increase the risk for these pelvic floor disorders. Moreover, even "normal" delivery can cause any of these conditions in the short- or long-term. Approximately one fourth of all adult women have symptoms of at least one pelvic floor disorder, and the number increases to one half by the age of 80 years.

I want to be clear: My point is not to promote cesarean deliveries. This surgery has its own dangers. The process of safely turning one person into two people is difficult and risky, no matter the approach. But the attitude that birthing via vaginal delivery is without effect is distressing and inaccurate and does a disservice to pregnant people.

What can we do? Appropriately educating, preparing, and consenting our patients and their partners for the ways their bodies could change as a result of birth should be the norm. We should also inform them that these problems aren't necessarily permanent. Urogynecologists and other pelvic floor specialists, such as physical therapists, have many treatments to recommend that can treat pelvic floor complications of pregnancy and delivery, including pelvic floor rehab, pessaries, medications, and procedures ranging from injections to reconstructive surgery if necessary.

Pelvic floor rehab after deliveries should be routine. I can think of no other medical situation where a structure as complex as the pelvic floor, which, again, contains all of our somatic and autonomic urinary and fecal control, as well as our sexual and reproductive machinery, would undergo a trauma event and not be rehabbed. Imagine not rehabbing after a stroke, orthopedic repair, or cardiac event? It would never happen. But because birth has been presented to us as a common and routine event, these injuries go untreated until they become severe. It doesn't have to be this way.

Rest assured, our patients are smart and strong. If they can handle knowing the risks and benefits of any other medical or physical process, they can handle learning the risks for birth and deciding for themselves how to proceed. And they will be grateful to you for arming them with knowledge.

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