Throughout my first pregnancy, I naively thought that I was completely prepared for whatever birth might bring.
During my medical training I had delivered babies, I had learnt about vaginal tearing in birth, I had seen patients with prolapse. I am a specialist doctor for older adults, which means I see people (sometimes even young people) with continence problems. With my extensive preparation for birth, high level of fitness and experience looking after people with incontinence, I thought I’d be back bouncing around at aerobics classes in no time.
However, I was in for a very rude shock.
I had a very prolonged labour of 38 hours, as my daughter had a posterior presentation; meaning her face was facing towards the front, so there is a bigger diameter of head to get through the cervix and vagina. After attempting to push for two hours, her heart rate showed that she was in distress and needed to come out quickly.
I was rushed to the operating theatre, but during that short time her head has descended just enough for a forceps delivery. This was the fastest way to get her out safely, but with the known risk of tearing pelvic floor muscles and causing prolapse.
Professionally I am very comfortable discussing continence with my patients, but at my six-week check up with my obstetrician, I was almost too embarrassed to mention my new incontinence. He didn’t engage in a discussion and referred me to a pelvic floor physiotherapist. I diligently did my pelvic floor exercises, as they had been prescribed and even tried electrical stimulation.
Listen: Trust Jessie Stephens when she tells you to stop putting soap on your pink bits! (Post continues after audio…)
Things got better, but were still far from normal by 12 months when I went to see a urogynaecologist. After some invasive and embarrassing testing, he told me I have mild stress incontinence and a small prolapse. He told me I would probably need surgery when I was done having children. This was before all the concerns regarding vaginal mesh repair came to light, but even then knowing that around a third people who have surgery will need to have this repeated, I was not keen on this option.
I’ve subsequently had two more children, with thankfully very straightforward vaginal births. I’ve also learnt (often by trial and error) that there are some key lifestyle measures to optimise pelvic floor health:
1. Learn to do your pelvic floor exercises PROPERLY
Often pelvic floor exercises are described as stopping the flow of urine, but the pelvic floor is a sling of muscles that goes from the tail-bone to the pubic bone. Doing the pelvic floor exercises there should be a drawing up sensation around the rectum, vagina and urethra. The next step is to activate the deep core muscles in the abdomen. Over time, you can then build up to co-ordinating all muscles at the same time.
2. Once you’re doing your exercises properly, get upright
It wasn’t until after my third pregnancy that I found Kristy Ahale at Stable and Strong. Kristy is a qualified exercise physiologist who specialises in post-natal recovery. Kristy helped me gradually move from doing pelvic floor exercises on my back, to being able to keep the pelvic floor engaged while exercising upright. I also learnt that if you can’t keep your pelvic floor engaged, you shouldn’t be doing the exercise. I have always been anxious to return to exercise and restrengthen my core post-partum, but by slowing down and doing exercises properly, my core strength actually recovered faster after my third baby than my first.
3. Avoid constipation
Constipation is passing infrequent or difficult to pass stools. This can lead to straining on the toilet, which can actually worsen a prolapse. A diet high in fibre is key to improving constipation because it makes the faeces bulkier and softer, so easier to pass. Fibre is the indigestible part of plant-based foods, like fruit, vegetables and wholegrains. Not only is this good for your prolapse, but diets high in fibre are actually linked to better overall health and a more diverse gut microbiome.
4. Watch your POOsition
Sometimes toilets have those signs to tell people not to crouch on the toilet seat. Although our toilets are not made to be stood on, crouching is actually the optimal position for defecation. When we sit upright, a loop of muscle naturally kinks our rectum, meaning that we have to strain more to poo. By placing a stool under your feet and leaning forward, you can get the optimal angle and avoid straining and the pressure on your pelvic floor.
5. Body positivity should extend to your vagina
Growing a baby inside your body is mind blowingly amazing. We are encouraged to be proud of our postpartum were stretch marks and our extra skin, but it is also expected that our vaginas do not look quite the same, since around forty per cent of women who have had a vaginal birth have some degree of prolapse. A mild prolapse is just as normal as the other post-partum changes.
6. Focus on functional recovery
Poor pelvic floor function is not an inevitable consequence of vaginal birth. With the right exercises and lifestyle measures, continence and sexual function can improve significantly, and it’s function not appearance that really counts.
When I was a medical student, we were taught that once a woman had a prolapse, it would just keep progressing, but more recent research has shown that this is not true.
Some women will have a more severe prolapse that is symptomatic and requires surgery, but even if this is the case these lifestyle measures are still important to avoid re-operation.
Personally, after some help from Kristy and optimising my diet, I am back to exercising regularly with confidence that I won't leak urine and my prolapse is no worse after my third child than my first. The most important thing I have learnt is that pelvic floor dysfunction is common, and very treatable.
As hard as it can be to overcome social conditioning not to talk about this topic, we need to start having these conversations, not just with health professionals but with friends, so that we can all access the right information and resources to enable an active life.
Dr Kate Gregorevic is a geriatrician (doctor for older adults) and PhD student. Her research focuses on frailty, ageing and positive health. She also has three children and relaxes with cooking and yoga. She writes about health, wellbeing and improving longevity at Elder Health Australia. You can also find her on Instagram @drkate_gregorevic.