The "Truth" about Pelvic Organ Prolapse

I'm not a Dr. Oz fan, but couldn't help noticing that he was talking about something not many women like to discuss: pelvic organ prolapse. I also was intrigued not only because of my birth nerdiness, but because I share some of these complaints and wondered: does anybody else?

Supposedly the "last taboo topic" in gynecology (nah, I think that'd be having a homebirth) I was curious, because I too was hesitant to talk about it. With strangers, sure; but friends - I wasn't really anxious to share that info with people I went to high school with (which is why I don't advertise my blog around casual acquaintances - I really don't want them knowing the intimate state of my vagina.)

Anyway, Dr. Oz revealed just how common pelvic prolapse - when your reproductive organs come out through the vagina - really is. The crowd was hushed as women in many age groups looked like they were hanging on to the edge of their seats. We all cruise through the female incontinence aisles at the grocery store (on our way to somewhere else, right?) and know those problems exist, and that they're actually pretty common. (There's even an entire company devoted to sending you your incontinence products, in discreet packaging directly to your house, so as to avoid being spotted at the grocery store.)

The primary risk factors are childbirth (especially after having several children), weight, and age. The problem is, Dr. Oz - and pretty much everyone else outside the birth advocacy circle - don't tell you that how you give birth can impact your risk factors.

If there's one thing I'd like to change about my vaginal birth, it's directed pushing. As one article on Dr. Oz's website said, "You take a genetic predisposition, a 9 pound baby, and three hours of pushing" and it's not a wonder we have these problems.

Back up a minute.

Three hours of pushing - even the one hour and ten minutes I pushed - is probably more common than it should be in hospitals. From my experience, I know I had absolutely no desire to push. Laboring down was not an option, and I wish I knew better to just wait for my body to do it on its own. Even if you were knocked unconscious, your body would still involuntarily contract and push that baby out on its own, but who has time for that anymore? It's rush rush rush to get the baby out (even in the absence of problems) and move on to someone else.

Consider what happens when you're constipated and trying to have a bowel movement. Pushing and straining - much like during childbirth - are probably going to do little more than produce a wicked case of hemmorhoids and even rectal bleeding. But if you wait until you have the urge (which is involuntary, much like pushing out a baby) it's a lot easier with a lot less work. So even though I personally detest the phrase 'it's like taking the biggest crap of your life' to describe childbirth, in some ways it can be compared, yes.

In the process of laboring down, the body can actually stop the labor process altogether, sort of as a last-ditch effort to conserve energy for the big event. And like a bowel movement, most women describe the urge to push as uncontrollable and something they just had to do. Unfortunately, I have never experienced that feeling, the feeling of knowing my body is doing something on its own volition because that's what it's supposed to do - not push a baby out at lightning speed just because somebody told me to.

In reading about the subject, some physicians simply blame childbirth in and of itself for prolapse, while others say traumatic childbirth is a cause. I'm not sure women realize there is any other kind, which is sad. Things like cord traction - literally pulling on the cord to get the placenta to detach from the uterine wall - is another risk factor. Forceps deliveries, episiotomies (again, largely unnecessary but done anyway) and prolonged, directed pushing are other causes, and yet all are considered standard procedure in many labor and delivery wards. In other words, we've experienced this crap for so long that we don't even know it's the cause - and that it's not really as normal as we think it is. We're normalizing the abnormal.

Many times, in an effort to avoid postpartum hemmorhaging after birth, they use cord traction to avoid a "retained placenta" - and cause even more bleeding as a result.

"Retained placenta" is another term I have a problem with. While the standard seems to be around 30 minutes after birth, it seems that, like everything else, it's different for everyone. While I'm obviously not an expert, I'd guess that in the absence of bleeding - and with the presence of breastfeeding right away - leaving it more than half an hour is probably okay. When I did some quick searching on it, I found several who said an hour, two hours - even 30 hours - and she lived to tell the tale. *gasp!*

More often than not it seems doctors are too quick to expect the placenta to come out and rush it with cord traction, which is often quite painful and dangerous if too much force is applied. I've also talked with people who agree their doctor was way too eager to detach the placenta and literally yanked on it - which can cause the very complications you're supposed to be preventing.

One study has shown that injections of oxytocin into the umbilical cord vein does not decrease the need for manual placenta removal; however, you're back to that murky definition of 'retained placenta' again. According to the article, retained placenta is more likely to happen to women in "wealthier nations." Not surprisingly, the study found that among women in the UK, Uganda and Pakistan, the women in the UK were more likely to have a retained placenta:

The researchers also found that the need for manual removal was higher in the United Kingdom (69 percent) than in Pakistan (62 percent) or Uganda (47 percent).

Many are quick to point out how dangerous it is to give birth in third-world nations like Pakistan and Uganda. While there is no doubt some truth to that, giving birth with overloads of obstetrical interventions - like in the UK - is probably just as bad. (Side note: not surprisingly, Uganda is the only nation of the three that doesn't have a relatively low rate of breastfeeding, which is often a good way to encourage the placenta to detach by itself. Incidentally, the CDC has determined that most US hospitals are severely lacking in their breastfeeding support, which could be further contributing to this problem. Add to that the frequent, often prolonged separation of mother and baby immediately following birth and it could add to further reliance on active management of the third stage of labor.)

Ironically, many in the UK scratch their hands and wonder why women in the UK are experiencing this problem, despite having access to all the best care and resources. Dr. Andrew D. Weeks of the University of Liverpool thinks prolonged cord traction might be an issue. Ya think?

Some sites list things like "unusually large babies" as a cause - perhaps it's more the interventions perceived as necessary in delivering that "large" child (and the idea that everyone has a different definition of what a large baby really is) that are key here. It's not uncommon for someone to have a very actively managed labor with a larger baby that results in significant trauma to the pelvic floor. Conversely, we hear of many women successfully delivering bigger babies with little if any tearing - which can depend on the birth setting. (Home birth? Natural hospital birth?) and the attendant (midwife vs. doctor? Someone who is more pro-natural birth?)

Sadly, doctors like Dr. Oz and urologist Jennifer Berman might hand out less-than-helpful advice because they've never actually seen a normal birth in progress. They often see the end result of years worth of obstetrical manipulation and intervention and chalk it up to just plain old childbirth itself, perhaps recommending an elective cesarean to avoid all that damage (even though studies have shown it doesn't). Yes, some women will be prone to this - for a number of factors besides childbearing - despite having an intervention-free birth. Some women get it and they've never even given birth. But until you can compare what often is and what could be, you have no real idea that the process is totally tampered with.

In doing some reading, I came across a very sad post by a nurse who experienced a pretty difficult birth, no doubt precipitated by the fact that she was induced at 37 weeks. The baby sounds like it just wasn't ready, but doctors attempted every means possible to get that child to come out, resulting in some nasty-sounding results. She wondered if she had a case against them because of everything she went through.

Some of the answers she got were quite shocking. Daring to call the normal 'abnormal,' she got berated, told she was a liar, and that what she went through didn't happen as she said it did. She was told that "controlled cord traction" was basically no big deal and an "acceptable practice." Maybe so, but it shouldn't be, especially in the absence of other complications. In the end, another forum user piped up and said "You think you had it bad??" as it to get into a virtual pissing contest about who could tell the most Horrible Birth Story Ever. I felt sad for the woman, not only because these women attacked her for questioning the status quo, but because they echoed what our legal system tells us: that unless you have something permanently wrong with either you or the baby, that you should just shut up and get over it.

After seeing some of the audience members on Dr. Oz's show, you realize that women have basically been giving birth violently for decades, perhaps even more than a century. I didn't see any hippie mamas standing up in the audience saying, "Well, I had a natural home birth and mother-led pushing in any position I wanted to, so I don't have that problem." She'd probably be stoned to death if she did. That, and the number of what we could call near-failed inductions - those where a vaginal birth happens but I'm not sure I'd call it successful, exactly - probably means more women are continuing to suffer.

While Dr. Oz's segment was titled "Suffering in Silence: The Shame of Pelvic Prolapse," I really think the people who should be feeling shame are those who insist on continuing these practices even though it's not in the best interests of their patients.

More reading:
Diagnosis and management of retained placenta after vaginal birth - Dr. Andrew Weeks talks about the risks and complications of retained placenta, but admits:

There is no consensus worldwide as to the length of the third stage after which a placenta should be termed "retained" and intervention initiated.

Controlled cord traction versus minimal intervention techniques in delivery of the placenta: a randomized controlled trial - This study suggests the use of CCT is beneficial and says that a continuous infusion of oxytocin were given to each patient after delivery of the placenta. I'm curious, though, what percentage of mothers breastfed immediately after birth, and how long were their placentas retained before someone decided to manually remove it?

Controlled Cord Traction During Third Stage of Labor - This study seems to contradict what the previous one said, in that

"Controlled cord traction (CCT) is actively promoted in combination with prophylactic uterotonics for the prevention of PPH. While the administration of uterotonics has been proven effective, there is no evidence of CCT being beneficial or safe. 

The purpose of the study was to determine: 

1. In women having term, single vaginal deliveries in hospital settings, in whom the third stage is managed with prophylactic oxytocin, does CCT produce a clinically significant reduction in the incidence of postpartum blood lose? (sic)
2. In these women, does CCT produce a clinically significant increase in the incidence of severe complications, including uterine inversion or the need for subsequent surgical evacuation of retained placental tissues and membranes (curettage or manual removal)?

Injections Aren't Solution for Retained Placenta: Study - ABC News
Management of the Third Stage of Labor - Medscape

The third stage of labor refers to the period following the completed delivery of the newborn until the completed delivery of the placenta. Relatively little thought or teaching seems to be devoted to the third stage of labor compared with that given to the first and second stages. A leading North American obstetrics text devotes only 4 of more than 1500 pages to the third stage of labor but significantly more to the complications that may arise immediately following delivery.^[1] One respected author states: "This indeed is the unforgiving stage of labor, and in it there lurks more unheralded treachery than in both the other stages combined. The normal case can, within a minute, become abnormal and successful delivery can turn swiftly to disaster."

While that may be true to some extent, why do our bodies have these built-in mechanisms to aid this natural, physiologic process?
Postpartum Hemorrhage - Wikipedia 

A Cochrane database study^[5] suggests that active management (use of uterotonic drugs, cord clamping and controlled cord traction) of the third stage of labour reduces severe maternal bleeding and anemia compared to expectant management. However, the review also found that active management reduced the baby’s birthweight and increased the mother's blood pressure, afterpains, nausea, vomiting, and use of drugs for pain relief. The number of women returning to hospital with bleeding also increased. Another Cochrane database study^[6], focusing specifically on the timing of the administration of the uterotonic drug oxytocin as part of the active management of the third stage of labour, suggested that administering the drug before the expulsion of the placenta did not have any significant influence on the incidence of postpartum hemorrhage when compared to administering the drug after the expulsion of the placenta.

 Eight Ways to Avoid Pitocin in Labor and Why You Should - Birth Sense blog 

Before you get that epidural ...

In many US hospitals, it's
reported that as many as
90 percent of women choose
an epidural when giving birth. 

Many people think that babies - especially newborns - are just floppy, drooling blobs that sit there and do nothing, completely unable to move under their own volition. This incredibly awesome video shows us how they can move up to their mother's breast - many within less than an hour of being born.

There are two groups: those who were the product of a natural, non-medicated birth, and those whose mothers had epidurals. Their behavior is markedly different, and yet most people think that medicated labors do not produce any effects in the newborn.

I don't know how that's possible. We know that babies can be effected by things in utero that we ingest; even taking Sudafed while nursing, for instance, can produce a jittery baby. There is some debate as to whether the medication crosses the placenta, and I think we can see in this video that there is definitely something going on, to say the least.

I've heard many people say this, including a labor and delivery nurse with supposed years of experience. I'm guessing she hasn't seen many unmedicated births in a while - and she holds the notion that painful childbirth is unnecessary and "why bother?" when you can get pain meds. One mom I talked to said she had an unmedicated birth and that hospital staff were "amazed" at how alert her baby was. No kidding!

In this PregnancyToday question and answer forum, a nurse who teaches childbirth classes asked if epidurals cross the placenta, mainly because a Bradley instructor was telling her clients that they do. The concerned nurse said that it was "her experience" that they didn't. I'm wondering how many natural births she's attended to know what to compare it to - it's a sad reality that many doctors and nurses have never, or very rarely, ever attended a non-medicated birth to know the difference in newborn behavior.

The response (it doesn't say from whom, by the way) immediately slams the Bradley instructor as having an 'extreme' view, and I'm not even sure the answer they gave makes any sense, really:

"As with every extreme position, there is a string of truth. Here are the facts: Local anesthetics cross the placenta. Local anesthetics are used in epidurals. Some local anesthetics placed into the epidural space will be absorbed into the bloodstream and cross the placenta. The small amount of local anesthetic from a properly placed epidural that is absorbed into the bloodstream and crosses the placenta should not affect the mentation of the baby. The lack of affect on the mentation on that baby is an advantage that regional techniques, such as spinals/epidurals, have over intravenous medications."

I'm not sure this really answers the question, and assumes way too much before suggesting that it doesn't ever affect the baby. In one breath, they say the drugs will go into the bloodstream and cross the placenta. Then they turn around and say they should not affect the "mentation" of the baby, but we can see, and some women experience, that it does in fact. Does that mean there are lots of bad anesthesiologists running around, giving bad epidurals? And does this mean they should really admit that the Bradley instructor is right?

I had two cesareans, so obviously I had a spinal for both. In my vaginal birth, I had Nubain but no epidural. I noticed a huge difference in behavior between my babies after birth. Coupled with my inexperience at breastfeeding the first time around, it was difficult to get my oldest to latch on and we spent days - literally - working at it before we were successful. With my second, she took to the breast as soon as I offered it (which, unfortunately due to mother/baby separation that is so typical in American hospitals, was probably at least an hour or two after her birth) and behaved much differently than her brothers did. I don't remember my third being that particularly alert or interested in the breast after birth (again, after being separated from me for several hours).

It could be said that in some babies, the epidural or similar anesthesia can diminish or totally destroy a successful breastfeeding relationship between mom and baby, or at the very least, create a more difficult start to breastfeeding than need be. An inexperienced breastfeeding mom may take this as a sign that baby is totally uninterested in her, and will decide before she even leaves the hospital that breastfeeding is not for her.

It's important to realize that epidurals can be great tools for allowing the mother to relax and labor to progress. But in some cases, they can slow down labor. This is another point of contention among some, but just the other day I heard the amazing birth story of a first-time mother who said that her labor was going pretty fast, and she noticed how the epi slowed it down. For her, this was a good thing because she felt that it allowed her to get her thoughts together. For others, it can be a nightmare that leads to more (and more) interventions, that can sometimes lead to a cesarean - or at the very least, a rather traumatic, difficult vaginal birth.

Studies have shown that epidural use can increase the need for tools such as vacuum suction and forceps - mostly no doubt because some women can't feel what's going on, nor can they get up and change positions when an epidural is in place. Many talk about "light epidurals" (even an anesthesiologist told me about these) but still lots of women say they were completely unable to move due to having one. Again, the jury is out as to whether this is really widespread and may depend on a number of factors, including mother's position and doctor/anesthesiologist preference.

Lastly, we must look at the standard procedure for birth in many hospitals: the mother is likely allowed no food or drink in labor, is encouraged to lie down frequently for cervix checks, is hooked up to a monitor for continuous fetal monitoring, and as a result, is not allowed to move around or really change positions. When it comes to pushing, she is often told she must assume the lithotomy position (flat on her back). When you add all that up, it's not a wonder so many women ask for epidurals and it's amazing a woman can even birth a baby at all.

Remaining upright in early labor can actually make the first stage of labor go faster, and being mobile during labor can help mothers cope with the pain better. Being flat on your back , confined to bed, does not.

It's important to realize that studies have been done, some of which produce completely counterintuitive results. Like, it would seem perfectly plausible that epidurals - especially ones that are "heavy" and allow the mother no sensation whatsoever - would slow down labor. Studies have shown, apparently, that this is not the case. But it's not just as simple as that: it's a multi-faceted issue with lots of pieces to the puzzle that need to be put together before you can draw any conclusion. Since many hospitals and doctors have little idea what normal birth is like, we base the results of many studies - and thus our conclusions about birth - on a completely skewed model of care. Therefore it's important to remember that some studies, however official-sounding, are inaccurate and inherently flawed, especially if they do not take into account those differences.

As I wrote about in this old post , if you choose to get an epidural, that's your decision. It should not be one that's taken lightly, but rather with as much information as possible, so that you have made an informed decision, not one that's based on someone else's perception of pain.

Do epidurals cross the placenta?
Facts on Epidural Anesthesia

VBAC survey online

A new birth survey is circulating from the ICAN Athens (GA) branch on VBACs and attempted VBACs, no matter what the outcome. Follow this link here to fill out the form.

The survey's authors, Makini Duewa and Michlene Cotter-Norwood, both have had VBACs. Michlene had a home birth after cesarean (HBAC), and Makini had a home birth after multiple cesareans (HBAMC). While the survey is ongoing, the authors say they need to have a great number of them filled out within the next five to seven days. Respondents can send the survey to makiniduewa@gmail.com.


Also, I invite you to take The Birth Survey if you haven't already done so!

The Double Standard of Statistics, Scientific Literature and Anecdotal Evidence

Wow, that sounds like more of a dissertation than a blog post. Which this could easily turn into, because I must be on a tear or something.

Yesterday I was surfing My OB Said What?!? and was equally amused and horrified to see that Dr. Amy had joined the fray of commenters. (She even brought one negative Nellie with her, unfortunately, although her post thankfully didn't make a damn bit of sense.) Somehow I welcomed it, though, because it makes for interesting debate and dialogue, all while exposing her typical urgency and unprofessionalism. It's hard not to while in that forum because of the negative, condescending comments of the readers - and who can blame them? As I told Dr. Amy, how can we not be condescending when we're used to, over the course of one or several pregnancies, having lies poured in both ears, over and over again, which have only served to either make us paranoid of our own normal bodily function or cause us to despise and demonize doctors and medical staff?

It's the same condescension offered up every day to pregnant patients, but now that the shoe is on the other foot, it's a totally different ball game!

I think Dr. Amy was getting a little paranoid, because she was definitely not in her own territory. Her pleas of "read the scientific literature! Ignore all the home birth studies because they are lies!" kind of made me laugh - a desperate grasping at straws to get us to turn from our 'ignorance' and come rushing in droves to the hospital. Remember my friend's home birth story I posted a while back? Especially how she was approached by an acquaintance who works in labor and delivery, who literally bribed her with a fancy vacation in order to prevent her from having the birth she desired and deserved? My friend R knows perfectly well, as do many, many homebirthing mamas, that if a true need for medical care should arise, they will be en route to the nearest hospital. Once there, they should not be treated cruelly or with disdain, and neither should Dr. Amy assume that all home birth advocates are out for the 'experience' only, ready and willing to put their baby's life in danger. Honestly, who in their right mind does that?

Dr. Amy told us to 'read the scientific literature.' Okay, I will. But after many of us have read that 'literature,' we're criticized. We're told (especially by Dr. Amy) that we cannot possibly understand risk, interpret statistics, or be able to decipher complicated medicalese. So which is it, doc?

We're also criticized for where we choose to obtain that knowledge: often, the Internet. Sure, you can't always believe everything you read on the computer - Billie Jo's Guide to Pregnancy might not be as reliable a source as any number of good birthing sites or blogs out there. But most blogs and sites I frequent do one thing: post links to studies and cite sources. Is that 'researchy' enough for you?

Many of the same medical journals our doctors read can be accessed by us, the average pregnant lady. Sure, they might be a bit difficult to understand if you haven't recently completed a college course in Medical Jargon 101, but some people do have the mental capacity to look up those terms to get a basic grasp of what they're reading. *gasp!* I know, this sounds crazy, doesn't it?!

The interesting thing about studies and statistics is that they can and often are flawed. When it comes to the safety of VBAC (a relative term, I know) I remember reading one doctor on a message board presenting the highest possible rate of rupture to readers, which scared more than one away from even attempting a VBAC. I cited another study that presented the actual rate of rupture as much lower, but again, because I'm just a woman with personal experience and no lab coat, it didn't mean much to them.

As far as studies and statistics go, you also have to be able to read between the lines. A lot. Some figures estimate that 85 percent of women who attempt a VBAC are successful. That does not mean that in 15 percent of women they experienced a catastrophic uterine rupture, hysterectomy or loss of baby. Some people tend to see that 15 percent as a failure and nothing more, which to them totally overshadows the 85 percent.

Another thing doctors have a problem with is anecdotal "evidence." "They're just stories!" many of them say. Who cares if your grandmother's neighbor's sister's aunt had a VBAC. That's only one person!

To me, birth stories are important. They must be - we tend to get into the nitty gritty personal details of our parts and their functions with perfect strangers when it comes to talking about birth, yet otherwise would clam up tighter than a drum. Somehow when it comes to the state of our cervixes, we are all too willing to share. And that's okay!

Take a group of five women who meet weekly for play date. Say three of the women have all been attended by the same physician and were all induced, all ending in a cesarean for either "failure to progress" or fetal distress. Mom #4 saw a different doctor, and mom #5 is newly pregnant, new to the ballgame and wanting to know as much as possible in order to have a normal, low-intervention birth. If that were me, the anecdotes of these women would tell me that the doctor who attended moms 1, 2 and 3 might be a little intervention-happy and it's time to move on.

Don't the stories of these women account for anything? They should, because the number one thing most pregnancy websites recommend you do when searching for a new OB is to seek the advice and recommendations of friends.

It doesn't take a rocket scientist to realize that when hearing the stories of moms, that the c-section rate is through the roof, that inductions are heavily used and often completely unnecessary. Even though you aren't reading their chart or conducting a formal investigation, these stories definitely say something, loud and clear.

The thing that gets me about 'anecdotes' is that they're only bad when they're coming from you. You can tell your doctor about the dozen or so moms who have safely VBACed and have healthy babies, and yet you're told to completely disregard the stories of these moms. Yet, when I was weighing my options with my doctors (two separate physicians, two different pregnancies) both physicians felt obligated to tell me about previous patients who had experienced ruptures. Were either of these women induced with Pitocin? I asked, only to get a muffled response of "I don't remember" both times. Either you're making it out to be something it wasn't, doctor, or they weren't even your patients - because if they were really catastrophic ruptures resulting in hysterectomy, loss of baby or mother, that's something you're unlikely to never forget. So what makes my anecdotes dismissed, and yet suddenly my OB is more credible? Isn't he, in fact, doing the very same thing I'm doing - telling a story?

The problem with all of this, especially "scientific literature," is that it seems like you can always find a study that tells you what you want to hear. There are no shortage of studies that say VBAC is safe, and yet there are those studies that say it's dangerous. It's all in how you interpret it, or how it's interpreted to you. If you're cornered in the doctor's office with a fear-mongering OB who only wants to sway you away from making the Big Decision to VBAC, it's going to come off as a lot more dangerous because of his/her influence.

Lots of studies have come out now to completely blow most of the outdated practices of modern obstetrics out of the water: the often unnecessary use of episiotomies, using a c-section as a way of  avoiding pelvic floor damage , inductions leading to a higher rate of cesareans , and the importance of both maintaining an upright position as well as taking in light food and fluids in labor. Actually, to some this is old news, and has been practiced by old-school midwives for centuries. Any woman can access this information from countless books, reliable internet sources, and other places, and yet this continues to be status quo in many hospitals around the world, despite the studies and literature that proves otherwise. So it looks like the only person who isn't "reading the scientific literature" is the doctor.

Ultimately, though, especially with doctors like Dr. Amy, the research you do will never be reliable enough, never be good enough, never be the right study. The rules constantly change as the game is played, and it seems like the pregnant patient is rarely the winner, no matter what.

Tell us something we don't already know

OK, so to most of us this is already old news:

Studies find that "Staying upright speeds the first stage of labor." But of course, we all know that "gravity doesn't help during birth." (insert major eyeroll here) Here's more on the best positions for labor and birth , and also some interesting highlights on why the most widely-used position in hospitals (lithotomy or in a "c shape") can cause more harm than good. Combine that with overuse of Pitocin and it's surprising anyone in a hospital can manage to give birth these days.

And this study shows that eating during labor has no ill effects.  Not surprisingly, the incidence of vomiting between the two groups studied was the same. Of course, we're not talking about a seven-course meal, here, but rather eating lightly. It's common sense that light food and drink during labor are going to give you energy that your body needs to undertake such a tremendous task!

We already have information that shows episiotomies are widely overused and often not even necessary , causing more damage than preventing it. But yet, they're still widely performed. We know that Pitocin can actually slow down some labors and cause problems in the infant that could be avoided, if only it weren't used in the first place. And yet both are standard procedure in today's delivery rooms world-wide.

The information is there, plain for all to see. The big (rhetorical) question is, why aren't doctors listening? Why is this not the norm?