I’ve Had a Cesarean in the Past.  What is the ‘best’ way to have my next baby?

Vaginal birth after cesarean section (VBAC) has been an obstetrical topic mired in controversy.  Up until the past few decades, VBAC was rarely attempted due to concern that the uterine scar might rupture under the forces of labor.  But over the years, it became clear that VBAC could succeed for most women who tried.  In 1987, the National Institutes of Health delivered a statement actively promoting VBAC as a safe and desirable alternative.

More recently, new debates have arisen regarding VBAC – and over which women are the best candidates.  The risk of pelvic floor injury, though often overlooked in this debate, may indeed be a factor worth considering – as higher rates of stress incontinence, sexual dysfunction and worse quality of life scores have been reported after VBAC compared to ‘repeat’ cesarean delivery.  More research is needed to clarify the risks and benefits of VBAC from the maternal pelvic floor standpoint.  The American College of Obstetricians and Gynecologists recently issued a statement stressing the importance of an individualized decision for each woman in each pregnancy, including those occurring after a prior cesarean.

What Can Be Done After Delivery, To Prevent Pelvic Floor Problems?

Despite a remarkable level of stress endured in the pelvic area during labor and delivery, most women devote little attention to their recovery afterwards.  Although childbirth is a ‘natural’ event if ever there was one, the physical recuperation is substantial – especially if you’ve had a long labor, large laceration, or episiotomy.  Right after childbirth, you can begin taking steps to rehabilitate your pelvic floor.

* Perineal healing may be enhanced by proper hygiene, and sometimes icepacks as directed by your doctor or midwife.

* Kegel exercises will help to restore pelvic floor muscle function during the postpartum period, before it is permanently lost.  Well-toned levator muscles may help to prevent post-reproductive symptoms before they ever arise.

* Good bowel habits and avoiding constipation are important for minimizing strain against the levator muscles, pelvic nerves, and any perineal stitches.

* Sensible work and play.  Leaping into a full and strenuous routine may stress your pelvic area, before it has a chance to properly heal.  Exercise, dietary and lifting habits should be reviewed.

* If Problems Persist … Ask the Doctor. A number of treatments – including physical therapy, non-surgical devices and behavioral training – can be used even during the postpartum period, if pelvic floor symptoms remain a bother despite self-remedies.

Will Breastfeeding Affect Incontinence and Pelvic Symptoms?

Yes, often for as long as you’re nursing.  Many breastfeeding women are unaware that a natural drop in estrogen – which persists for as long as you’re breastfeeding – may cause urinary incontinence to become more severe, and may lead to vaginal discomfort and sexual pain. If your symptoms are mild, simple remedies including the use of vaginal estrogen therapy may be helpful.  It’s not necessary to delve into a full medical evaluation until a few months after you’ve finished breastfeeding, if your symptoms are still bothersome.

Adapted From:  “Ever Since I Had My Baby: Understanding, Treating and Preventing the Most Common Physical Aftereffects of Pregnancy and Childbirth”, by Roger P. Goldberg, MD MPH

(Crown Publishers, Random House, NY 2003)

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