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.

Comments

[Laura]

Thank you for this, it is very interesting. I don't understand the "falling" part, but I've had a lot of pain, it's nice to see I'm not alone in this.

[Cat, Galloping]

Gah. This is why I scheduled a c-section.

However, after many many years of vulvadynia, I have a certain amount of experience in this area. I do recommend finding a specialist and keep trying new doctors if that doesn't help. I actually saw a specialist in NYC and I'm kind of mad at myself for sticking with her for so long when she wasn't helping.

My situation is different from the questioner's, but I'll throw this out there in case others have this. I had pain at penetration, not during, and then a HUGE amount of pain afterwards.

After my miscarriage, when we were waiting to try again, we used condoms for the first time and all of that afterwards pain went away. My theory is that I was being rubbed kind of raw and the condom prevents semen from irritating these "wounds".

While condoms aren't ideal for my husband, he certainly prefers them to hurting me (being afraid of causing or having pain is the least sexy thing I can think of). I wonder if I was the only married pregnant woman on the planet buying condoms?

[Megan]

I think the best piece of advice I can reiterate is to keep seeking out help if it doesn't feel right. I couldn't use the restroom without pain for 6 months and it was about a year before sex felt okay.

I had a preciptious birth with my daughter (3 pushes). I had planned an unmedicated delivery and had early labor for a long time, but the end was very fast. It was just my husband, my mother and the nurse who was across the room as my daughter was born.

I had some severe tearing and a hematoma - it was bad. The worst, beyond the physical pain, was my OB not really believing it was "that bad", not offering any kind of pain relief/suggestions until 12 weeks postpartum and telling me that "this is what you get for having an unmedicated, uncontrolled delivery". (yes, I switched OBs)

I went to another OB who was more helpful and less judgmental who helped me with the more immediate issues of healing and was referred to a urogynocologist to assess structural issues (no surgery necessary at this point).

I had my second six months ago and when my water broke, I experienced some major anxiety as the first experience and the aftermath came flooding back in that moment. I had another unmedicated delivery and while it went fast again, it wasn't nearly as fast as the first time and I had only one small tear.

I really feel for the writer of this question, and anyone else in a similar situation, but I did finally get to a point where I was ready to do it again. The recovery the second time was amazingly easy comparatively.

[J]

My dr and nurses were great but my labor was difficult because the baby was sunny-side-up. I tore both ways after several hours of pushing. It's now 4 months later and I have a lot of pain during sex. It feels like I am tight and hard...does that make sense? I have problems with leaking as well but I do not experience pain outside of sex. I'm desperate to have this go away.

[cmm]

I had a fast delivery and minimal tearing, but sex was excrutiating for months. We tried tons of lube, different positions with no improvement. I went to the doctor and she said that the vaginal lining gets sloughed off and is maintained in a quasi-menopausal state while breast feeding. Estrogen pills (Vagifem) inserted vaginally helped somewhat, but the real trick has been time. Once I started menstruating again about 8-9 months out, sex is SOOOO much better.

[Reader]

Hi, I'm the reader who asked the question. It is actually very useful to know this is a somewhat uncommon issue--I thought everybody was going through this but nobody was talking about it! I had also never heard of urogynecologists before. There are several of them in my area so I'll definitely look into seeing one of them.

My OB did mention surgery as an option, but suggested that I wait until I'm finished having children before I have it done. In the meantime, more Kegels!

[Menita]

I had a super-fast delivery (45 mins of hard labor) with ugly tearing, and while nothing feels loose, had no problems going to the bathroom and the soreness vanished in a few weeks, intercourse is still excruciating. Yes, I lubricate. But still. I've wondered about bringing it up with my doctor, except at 33 weeks I probably should have other things on my mind...But I wonder if there's something they could look at/fix when they're sewing me up this time.

[Menita]

Reading cmm's comment about I wonder if being pregnant again so soon had sthg to do with it. I breastfed my daughter until she was 4 months, and got pregnant again on the fifth. I wonder if it's that all sorts of hormonal nonesense is going around down there...

[Cat, Galloping]

Menita, you should definitely mention it to your doctor. Bingo's birth might be a good opportunity for them to do some clean-up down there if, say, there's scar tissue. Maybe not, but it can't hurt to ask.

[sarah]

moxie you're brilliant. what a great post. thank you so much for putting this information out there in such a useful way!

[Essi]

Thanks for broaching this tricky (or should I say 'trickly'?) subject. I gave birth 12 weeks ago, with a long prelabour, over 2 hours of pushing, forceps and a 2nd degree tear. During the 2nd stage of labour I could feel my pelvic floor getting progressively weaker and weaker and I was urinating with each push (sorry TMI). Since then I've had the pain on intercourse and a fair degree of urinary incontinence. None of my friends, sisters or my mum have had this problem after their deliveries (or they're not fessing up!) The maternal and child health service (a free service here in Australia) referred me to a Physiotherapist, who could only suggest just your garden variety, every day kegel exercises. Does any one know where to find out about some more 'aggressive' exercise? I think its time to pull out the big guns!

[Cory]

I really didn't have pain-free intercourse until about 9 months. I had a 2nd degree tear and things just didn't feel right, or downright hurt, lube or not, for a long time. I think what's difficult is the random cleared-to-have-intercourse-at-3-months idea. Turns out lots of other friends didn't have comfortable sex until much later than that, too.

And, one tip I got from my OB is to do Kegels during pregnancy while you're sitting at traffic lights (obviously wouldn't work for you walkin' city slickers).

[Moxie]

Menita, I'd look at the augs.org website, see a urogynecologist, and talk to him/her about it and see what they say. If there's something that can be done at the time you're having Bingo, that's going to simplify life for everyone. (Although I predict your delivery with Bingo is going to be in no way as traumatic as Polly's was, so there may not be any stitching going on anyway.)

Essi, it looks like the pelvic floor therapy can involve guided Kegel exercises with biofeedback sensors and a physical therapist. (When I sprained my ankle a few years ago my PT was named Vinnie, and while he was very nice and was great with my ankle, the thought of him doing pelvic floor PT is making me laugh and writhe uncomfortably.) But this site, written by two PTs specializing in pelvic floor therapy, makes it sound like there's plenty more involved:
http://www.ourgyn.com/article_retrieve.php?articleid=184

I wonder if you could research urogynecologists in Australia. Or contact the augs.org people and ask if there's an equivalent society in Australia?

Cory, we city folks do our pregnancy Kegels on the bus or subway.

[M]

I had a very easy labor and delivery with my first: no epidural, 30 minutes of pushing. I felt back to my normal self within the week. So it was shocking that I was "blown out" down there, for lack of a better description. Sex was terrible. Not painful, just no sensation whatsoever. My doctor was pretty dismissive, lecturing me to do my Kegels. I did, faithfully, all day, every day. I leaked urine when I coughed, sneezed or laughed, and couldn't wear tampons because they slid right back out. Right before my son turned four (and right before I was ready to demand some type of surgery), everything suddenly corrected itself. Sex was great again, tampons were fine, even the bladder was better. I was, however, terrified to ever give birth again. I was so scared that I put if off until there was a ten-year age gap between my first and second. I made the incredibly controversial decision to have an elective cesarean with my second. I had no idea I would be so harshly criticized for my choice. In my mind, it was my only choice. Although many people question the decision I made, I never regretted it. I had a huge daughter with massive shoulders, and I was so glad that I hadn't been forced to deliver her vaginally. A c-section is no picnic, and there are definitely drawbacks to having one, but for me it was right. Sex is great, my tampons fit, and I don't leak urine. Ever! I would never encourage someone else to have an elective cesarean, but it is a choice. I just wish others would be more understanding and respectful of the choice I made. If they walked a mile in my old vagina, they probably would be!

[jenny]

I haven't experienced any "down-there" problems post-partum... I did kegels regularly after birth, and was pretty good about doing them every time I went to the bathroom.

I would like to make kegels a part of an exercise regimen, and continue doing them regularly... but I find them too darned distracting because they make me, well, aroused!

Does everyone get a bit stimulated from doing kegels? Or am I perhaps doing something wrong...?

It sounds like kegels are a really beneficial exercise, so I know I should be doing them. There are certainly worse things than feeling "fired up" at odd times of the day, but I find it really distracting, and tend to avoid them. Any advice that will encourage me to just get over it already appreciated.