Birth is an amazing process; a process that the female body is built to experience. The process is not simple and neither is the female body.
It’s complex, it’s impressive. And often misunderstood.
With misunderstanding or misinformation often comes fear. Many women fear birth as a result of not fully understanding the process (“I have to squeeze something something the size of a watermelon out of an opening the size of a lemon?!”). And for the same reasons, many women fear the post-birth vagina (“Will I ever walk the same again?!”).
So instead of leaving this topic as yet another “untalkable” in the field of women’s health, let’s ease some fears and start with a quick lesson about the female anatomy.
The uterus and cervix: the uterus, “the womb”, is where baby lives so cozily for those 9-10 months of pregnancy, while the cervix is the amazing connector of the uterus to the vagina. It’s like a turtleneck at the bottom of the uterus, opening into the vagina. The cervix stretches, softens, and thins out as it prepares for the passage of a baby during labor and birth.
The vagina: it’s strong, it’s flexible, it has serious endurance. In other words, it is one physically fit body part! It’s the passageway by which a fetus travels from the uterus, through the dilated cervix, to the arms of the outside world. The vaginal walls have four layers of cells, tissues, and muscles that allow for the significant expansion required for the descent of a baby. After this amazing stretching, it takes weeks to months for it to return to its pre-pregnant size, and some sources say it will always be a bit larger than it was before pregnancy (Ricci & Kyle, 2009).
The vulva: this is what people often refer to as the vagina, but the vulva is actual the outer opening to the vagina that is visible from the outside. Known as “the covering” in latin, the vulva includes all of the external female reproductive organs, including the clitoris and labia minora and majora.
The perineum: this is the skin, muscle, and fascia (tissue) located between the vaginal canal and rectal canal. This area of the woman’s body also has the amazing ability to stretch, though it doesn’t always stretch as easily or as much as we’d like! This area can tear during the pushing process of birth, with several degrees of possibility:
a first degree tear is considered “superficial” and usually requiring very little, if any, repair, and heals rather quickly.
a second degree tear goes into the layers of the muscle and each layer will likely require stitches. The healing process may take a few weeks before discomfort is gone.
Third and fourth degree tears run deeper, from the vaginal opening into the anus and potentially into the tissue underneath the anal sphincter.
These tears occur in about 4% of women who have vaginal births but are more likely to occur in certain situations like baby being born in the posterior position, or in vacuum or forcep-assisted deliveries.
In the past it was believed that performing an episiotomy (cutting the woman’s perineum to enlarge her vaginal opening) would make birth easier and prevent erratic tearing. It was also done with the idea that stitching a straight cut would be easier and more straightforward, though it was ultimately found that extra tearing happened more easily when an incision was already made. Episiotomies are no longer routine and instead are used in urgent situations, like during instrument-assisted deliveries or when the baby appears in distress.
Some women will tear in or near other places like the urethra, labia, or clitoris. Before we get to treatment of tears, let’s talk about prevention. Can you prevent tearing? Maybe. When it comes time to push, follow your urge, but take your time and allow your birth team to guide you. Using warm compresses on your perineum while pushing may help it stretch, too. OBs and midwives can also help with some gentle perineal stretching as the baby is crowning. Talk with your care provider before birth to learn more about their suggested strategies to help prevent tearing. There are no guarantees, though. Much of this depends on the size and position of your baby, and your particular body’s perineal tissues.
Treatment for tears or episiotomies may start with stitches, after the area has been numbed, though some tears will heal just fine on their own. Then it’s all about ice packs, peri bottles (spraying warm water over the vulva while urinating), cool witch hazel-soaked pads, maybe some stool softeners or pain relievers, and most definitely time. It may take days, weeks, or even months before affected women feel “normal” again after childbirth.
You may wonder, “Will I ever really feel ‘normal’ again?” Your cervix and vagina will never quite be the same, and this is nothing to be ashamed of! (I mean, seriously: You just brought forth life!) You’re not likely to ever notice the difference in your cervix, but will the rest of you actually FEEL normal again? Much of this depends on the condition of your pelvic floor.
Pelvic floor: The layers of the pelvic floor include muscles, connective tissue, and ligaments, all forming a hammock-like structure from the pubic bone to the sacrum. No matter how a woman gives birth (via abdominal cesarean or vagina), the pelvic floor is stressed from all of the baby weight it has supported for many months. Some women may feel like they can’t control the flow of urine or their bowels as well after pregnancy. Sometimes the pelvic floor gets so stressed and weakened after pregnancy and childbirth that prolapse may occur. This is when there is so much pressure on a weak pelvic floor that organs like the uterus, cervix, bladder, or bowel actually start to come out of the body. This is more common than many women realize: up to 50% of postpartum women have some degree of prolapse. Restoring the strength of the pelvic floor can take six months for some women.
So what can you do to help?!
A Cochrane Review in 2011 compared pelvic floor muscle training (PFMT) with other treatment options like lifestyle changes (i.e. no heavy lifting) or surgery. Per usual, more research is needed, specifically comparing PFMT with surgery, but they did find PFMT to be successful in improving prolapse symptoms and pelvic floor muscle function.
Ok, then… what exactly is PFMT? It usually includes kegels: exercises that strengthen the area around the vagina and rectum. Gently squeeze these muscles, as if trying not to pee, and then release them 5 seconds later. This is a kegel! (Remember to keep your belly and butt relaxed, and focus on just the pelvic floor.) Do quick kegels five to ten times, or hold a kegel for 5-10 seconds and repeat five times, and your workout is done! Keep note: more doesn’t necessarily mean better here. Tightening this area too much without balancing the surrounding muscles can make for more leaks. So what does that mean? Squats! That’s right; everyone’s favorite exercise! The theory here is that stronger glutes (butt muscles) will only help strengthen your pelvic floor. So, squat away! http://breakingmuscle.com/womens-fitness/stop-doing-kegels-real-pelvic-floor-advice-for-women-and-men Building and stabilizing your core muscles also help prevent those annoying leaks by relieving some of the stress on your pelvic floor, so attend a postnatal yoga class whenever possible and try incorporating some of these exercises into your routine, too: http://www.prevention.com/fitness/strength-training/pelvic-floor-exercises-prevent-urinary-incontinence If you’re still not feeling improvement, don’t hesitate to contact your doctor who may be able to connect you with a physical therapist who works with postpartum women.
It’s true: having a baby changes you forever. Emotionally, mentally, and physically. And although our hearts are permanently swollen with love for our babies, have no fear: the swelling is just temporary for our parts. 🙂
(Go here to read about one woman’s hilarious experience with pelvic floor therapy: http://www.huffingtonpost.com/lynn-shattuck/pelvic-floor_b_4251668.html)
Hagen, S. & Stark, D. (2011). “Conservative prevention and management of pelvic organ prolapse in women”.Cochrane Database Syst Rev 12: CD003882.doi:10.1002/14651858.CD003882.pub4.PMID 22161382.
Ricci, Susan S., & Kyle, Terri (2009). Maternity and Pediatric Nursing. Lippincott Williams & Wilkins. p. 431.ISBN 0781780551.
Wylie, Linda (2005). Essential Anatomy and Physiology in Maternity Care. Elsevier Health Sciences. pp. 157–158. ISBN 0-443-10041-1.
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