Obstetric Factors

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The vaginal birth process represents the common denominator for many pelvic floor dysfunction symptoms. Our understanding of neuromuscular damage, which occurs during the vaginal birth process, has been enhanced with the use of neurophysiologic testing and endoanal ultrasound. As such, the vaginal birth process not only results in significant stretching of the levator musculatures in a vertical direction, but, more importantly, in stretching of the pudendal nerves in the vertical direction. Any stretch of a somatic nerve of more than 12% has been reported to lead to a degree of permanent injury to that nerve. During the vaginal birth process, perineal descent results in stretching of the pudendal nerve to a degree in which permanent injury can result. Beyond direct injury to muscles and nerves of the pelvic floor, the vaginal birth process also results in significant symptomatic as well as occult injury to the anal sphincteric mechanism. Many anal sphincter tears are symptomatic. However, it is unknown whether occult anal tears will result in subsequent fecal incontinence a few years postpartum.3 It is thus not surprising that there is a high incidence of postpartum flatal and fecal incontinence.

An aside should probably be made at this point. Our increased understanding of the neuromuscular consequences of the vaginal delivery process has been the subject of much debate in the recent past, especially as relating to the acceptance of elective, on-demand cesarean delivery. Many cultures around the world have already espoused and accepted this concept for various reasons, including resultant pelvic floor dysfunction. In the United States, this topic has been the subject of significant debate among obstetricians and gynecologists. The urogyneco-logic stance on this has been one of providing patients information regarding potential consequences of pelvic floor dysfunction and allowing patients to make a decision whether they wish to undergo an elective cesarean deliv-ery.4 In a preliminary survey of pregnant women, it seems that providing women with information regarding potential pelvic floor consequences of a vaginal delivery does not alter their decision-making process significantly.5 Nevertheless, providing patients information regarding the risks and benefits of the vaginal delivery process, as with any other invasive procedure informed-consent process, will likely become a part of antepartum obstetric care.

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Pregnancy And Childbirth

Pregnancy And Childbirth

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