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Pelvic Health & Childbirth

pelvic health cover

During my research I made ample use of the Internet to determine what books have already been published on maternity, childbirth and related topics. Some of the large Internet book vendors have bulletin boards where people can write their comments about particular books. This makes fascinating reading since the comments clearly indicate what people like and dislike.

As regards obstetrical topics, it seems the ability to reassure counts most highly. This is quite understandable since we all like to be told that everything will be all right. The reason for this book, though, is that I know that everything is not all right. My intention is not to make false reassurances - but to alert. There is a serious threat to women's health and it is not being addressed adequately. Worse, I fear this problem is being ignored and downplayed to the detriment of many women.

"A good plan today is better than a perfect plan tomorrow" 7

and

"Wisdom consists of knowing when to avoid perfection" 8

3 "Principle of design inertia": The Complete Murphy's Law; Arthur Bloch; P105

4 "Wilkie's Law": The Complete Murphy's Law; Arthur Bloch; P81

5 "Williams and Holland's law ": The Complete Murphy's Law; Arthur Bloch; P123

6 "Mayne's Law": The Complete Murphy's Law; Arthur Bloch; P86

7 "Patton's Law": The Complete Murphy's Law; Arthur Bloch; P73

8 "Horowitz's Rule": The Complete Murphy's Law; Arthur Bloch; P85

Although it is of utmost importance, I also strongly believe that there is more at stake than the health of the baby alone.

"Nobody notices the big errors"6

When one looks closely at the mother"s health outcomes and especially at long-term effects of vaginal birth on her pelvic floor specifically, things become a lot more complicated. I see women almost every day who come to my office with severe problems related, too large degree, to their vaginal childbirths. These are the women that leak urine into their underclothes when they cough, sneeze or do physical activities. They have to wear constant protection. These are the women who have to pay attention to where the closest washroom is - constantly. These are the women with pelvic discomfort and sexual dysfunction related to sagging pelvic organs, and these are the unfortunate women who curtail enjoyable activities for fear off embarrassing episodes of loss of control.

The unfortunate fact is that we simply have no way to determine for which women these problems will become a reality. Individualization is therefore, unfortunately, difficult to introduce and more global strategies will have to be considered by patients and their caregivers alike.

I) CHILDBIRTH The importance of the pelvic floor: How can this possibly be important? Most people have never even heard of the pelvic floor. Yet, the truth is that this complicated structure is of immense importance to the health and welfare of every single human being. In the case of women, the pelvic floor forms a vitally important part of womanhood and is essential to some of the most private and intrinsic bodily functions. An appreciation of this structure and its complex role in health, as well as the specific disorders directly attributable to it, is just beginning to take root in the medical community. The lay population and those who would benefit most from knowledge of the pelvic floor, pregnant woman, are mostly unaware of its existence. This is despite the fact that pelvic floor disorders destroy the quality of life of millions of women worldwide. The pelvic floor defects and disorders experienced by the majority of women are directly related to vaginal childbirth. Although obstetricians are well aware of this fact they are, for the most part, unable to do anything about it. To some degree this sorry state of affairs is the outcome of many factors beyond their control, such as cultural, political, and economic factors. Other factors include insufficient research and guidelines, inadequate attention to the pelvic floor during residency training, and a certain degree of apathy. Although it is almost impossible to predict which women will develop pelvic floor damage during childbirth, the current situation is simply unacceptable, and all the more so, I believe, because there is hope.

About The Author

Magnus Murphy, MD

PRACTICE AND EXPERIENCE:

Dr. Murphy is the current Division Chief of the Division of Urogynecology and Pelvic Floor Disorders of the Calgary Regional Health Authority and is a Clinical Assistant Professor at the University of Calgary in the Department of Obstetrics and Gynecology.

He received his undergraduate medical degree from the University of Stellenbosch in South Africa in 1987. After a year working in Namibia as an intern, and two years obligatory military duty, he did his residency at the University of Stellenbosch. He obtained his masters degree in Obstetrics and Gynecology in 1994. In the same year, he obtained Fellowship of the Colleges of Medicine of South Africa in Obstetrics and Gynecology.

He obtained his Royal College of Physicians and Surgeons of Canada Fellowship in 1995. He is a Fellow of the Society of Obstetricians and Gynecologists of Canada, founding Chairman of the Western Society of Pelvic Medicine and a member of the American Urogynecologic Society. Dr. Murphy practiced in British Columbia, Canada, for seven years prior to moving to Calgary, Alberta, Canada

Previous:

Specialist Obstetrician and Gynecologist in British Columbia, Canada
Chairman, department of Obstetrics, Cranbrook Regional Hospital
Acting Chief of Staff, Prince Rupert Regional Hospital
Chairman, perinatal committee, Prince Rupert Regional Hospital
Chairman, continued medical education committee, Prince Rupert Regional Hospital

Education:

Fellow, Royal College of Surgeons of Canada
Fellow, Society of Obstetricians and Gynecologists of Canada
Masters degree (cum laude) Obstetrics and Gynecology; Stellenbosch University South Africa
Fellow, College of Obstetrics and Gynecologists of South Africa

One inevitable result of the climate of guilt that the "natural" enthusiasts promote, is the feeling of failure in those women who do not successfully deliver their babies vaginally without instrumentation or at all. Not only is this a likely explanation for the recognized higher incidence of postpartum depression in woman undergoing cesarean section (discussed in more detail in the cesarean section chapter), but it can also potentially interfere with the new mother"s bonding with her newborn baby.

Although I can understand to wish to do things "naturally", I am sometimes amazed by the irony of this concept in the obstetrical field. It seems that "natural" means different things to different people. After all, how natural is it to ingest vitamins and extra minerals in doses far higher than the amounts usually acquired through normal diets; to undergo various invasive antenatal tests and screening; to take medications and antibiotics, and to deliver in a sterile hospital environment with aseptic technique? Of course, as shown, some want to return to the Stone Age. My problem is not at all with the wish to accomplish the delivery of the baby vaginally without unnecessary help. That is certainly a laudable and very positive thing. My problem is with the concept currently being promoted by various groups that intervention during childbirth, except in extreme cases, is almost always unnecessary, unnatural and detrimental. Much has been made in the media, as well as certain publiCations and books, about the fact that specialist obstetricians have a higher intervention rate than midwives. This is used by lobby groups to push their own agendas, in this case, the minimalist approach. This, to my mind, is similar to stating that a corporal does a better job than a general, because the general"s decisions will probably lead to a higher loss of equipment and personnel in battle. Of course the obstetrician will have a higher intervention rate. He or she was, after all, trained to do just that and safely too. They will naturally receive most of the complicated cases that require intervention, even if the patients started off as low risk, primary care cases. With statistics thus skewed, one can easily seem to prove any point:

"If enough data is collected, anything may be proven by statistical methods" 5

Unfortunately, some obstetrical societies have "bought into" this thinking. To a large degree this agreement by clinicians is a result of the lack of concern (or interest) about the long-term effects of vaginal birth on future pelvic floor function.

I might seem unnecessarily critical of the "natural childbirth" movement. Although I believe that many good things have followed from this movement, I believe that the pelvic floor is natural childbirth"s (still unrecognized) Achilles heel. I agree for instance that in the case of a healthy fetus a long second stage of labor will not necessarily have any detrimental effect on the baby, but the effects of prolonged second stage labor on the mother"s future quality of life has been overlooked.

Today many, if not most, pregnancy books on the market are fueling the idea that less is best as far as medical interventions are concerned. So-called "natural childbirth" has become the "in" phrase, and those who use the term tout vaginal births as the only acceptable outcome except in extreme circumstances. The "natural" is taken to indicate that only the least intervention possible (be that pain relief, monitoring or methods attempting to expedite delivery) is acceptable. Numerous examples of successful vaginal births illustrated in these books followed horrendous labors that, without exaggeration, may be described as ordeals where the limits of safety were severely tested. In spite of this, these births are hailed as success stories. Prolonged second stage labor (when the cervix is fully dilated and the mother is pushing) is considered to be of no harm. Any intervention by the obstetrician is regarded as unnecessary meddling which robs the patient of her chance to have a normal vaginal delivery.

Just listen to the following examples from "Pregnancy & Childbirth Tips" by Gail J. Dahl:

"My pushing phase was eight hours. I had read about a VBAC woman who pushed for twelve. I was hoping not to win the record, but knowing that there is wide variation to all phases of labor helped me. I am so proud". And the following: "My wife has a classical scar from a cesarean section. Although we have never met, I knew you would be happy to know the result, a beautiful homebirth with a midwife. Her labor was 57 hours and she pushed for an additional three. Our baby was 9 lbs 4 ounces". I also want to quote the last two sentences of chapter 6 on page 72: "If you don't want an episiotomy, or a forceps delivery, or a cesarean section, you simply make certain that when you are in labor you have chosen a place where these procedures are unable to be performed. It these as simple as that". Unbelievable – what century does the author live in? These, as well as other irresponsible viewpoints seem to have acquired some following and degree of acceptance.

Contrary to the council of the "give us back our natural labor" school of thought, the cesarean section rate has increased over the last two decades to unheard of percentages. These statistics may be attributed, in part, to increased fear of litigation, but also to progress in the field of obstetrics and neonatology. Fetuses that, in the past, had little hope of survival are today safety delivered by cesarean section. Increased uneasiness with certain operative vaginal delivery procedures, partly as a result of fear of litigation in case of fetal or maternal injury, has rendered many of the procedures previously performed to accomplish vaginal delivery, almost extinct. A good example of this is the elective vaginal breech delivery. These changes have raised alarm in obstetrical circles, because many skills are rapidly being lost as a result. There are currently well publicized attempts throughout the western world, to decrease cesarean section rates, but the success of these efforts varies. Although led by obstetrical societies, with their concomitant academic considerations, the pressure is was definitely brought to bear by the consumer groups, feminists, politicians, health maintenance organizations and the insurance industry. These groups all have their own motivations, which, more often than not, are monetary.

One aspect of childbirth that suffers neglect is the late complications of vaginal birth. Although pelvic floor injury during childbirth is a well-known problem, it has received little attention until recently. The problem of pelvic floor disorders, as they present in later life, and childbirth, as their most likely cause, are mostly still treated as two separate issues. Recent years have witnessed a tremendous increase in medical publications concerning research into pelvic floor disorders and their possible causes, but this new awareness has not yet filtered through to the public domain.

The above changes were however coincident with dramatic falls in both maternal and perinatal mortality (deaths of mothers and newborn babies) and morbidity (complications). These rates are currently so room in many Western countries that, logically, they cannot be expected to drop much further. One could be excused for the assumption that everyone would be happy. Alas, no. The advent of such rapid change and the often dehumanizing face of modern obstetrics ensured that a backlash was not long in coming.

Today most maternity units try to create a more homelike atmosphere. Not too long ago fathers played a peripheral role in the childbirth process, whereas now they are welcomed, and encouraged to be integrally involved throughout the experience. More and more women have returned to the midwife as primary caregivers, and in many areas where home deliveries had declined, including North America, they are making a comeback. Today's women read multiple books on labor and delivery, and they work out birthing plans, which are then presented to their healthcare provider or labor attendant. This often irritates physicians greatly, and they bemoan the loss of their hitherto unchallenged professional autonomy.

"A good slogan can stop analysis for fifty years"4

The female pelvic floor is one of the most important organ systems involved in women's health. Its correct function is essential to many important aspects of the female life experience. Pelvic floor dysfunction or damage could have devastating consequences for quality of life. Most women are ignorant of the importance of the pelvic floor and may not even know that it exists. Unfortunately, vaginal childbirth may lead to severe damage of the pelvic floor and its component structures, with resultant negative effects. Many of the effects of the damage caused by vaginal childbirth are not experienced immediately, and commonly appear years later. I believe this is one of the reasons why the detrimental effects of vaginal childbirth have not been adequately appreciated.

Choosing Cesarean Birth:
An alternative to today's Crisis in Natural Childbirth?
by Magnus Murphy, MD

choosing cesarean right

original manuscript

Dr. Murphy welcomes you to send your comments via This email address is being protected from spambots. You need JavaScript enabled to view it.

This manuscript is an unedited rough original from which the final book, "Pelvic Health and Childbirth" grew (available for purchase here). The arguments developed in this rough manuscript were developed further and many new chapters, ideas and resources made it into the book.

There are however also original parts in this manuscript not in the book. I dare you to read the entire manuscript and then go to the discussion forum to give your opinion.

Table of Contents

  • Childbirth
    • ♦ Why this book is different ♦ The importance of the pelvic floor ♦ Advances in labor and delivery ♦ Informed consent ♦ The politics of childbirth ♦ Culture in childbirth ♦ The money factor ♦ Demographics ♦ Your physician's dilemma ♦ A silent epidemic
  • The Pelvic Floor
    • ♦ Why the pelvic floor has been neglected ♦ Attributes of the pelvic floor: * Support * Dynamic involvement in bodily functions * Safety net * Sexuality ♦ Evolution and childbirth ♦ Understanding the pelvic floor ♦ The working of the pelvic floor muscles ♦ The pelvic fascia ♦ Pelvic nerve injuries
  • Pelvic Floor Disorders
    • Urinary incontinence:
      • ♦ Effects on quality of life ♦ Prevalence ♦ Types of urinary incontinence ♦ Urinary incontinence and the pelvic floor ♦Urinary incontinence and vaginal delivery ♦ Four non-surgical treatment options for urinary incontinence ♦ Surgery for treating urinary incontinence
    • Anal incontinence:
      • ♦ Understanding anal incontinence and anal continence control ♦ Anal sphincter injuries ♦ Episiotomy and tearing ♦ Surgery
    • Genital prolapse:
      • ♦ Uterine prolapse ♦ Cystocele ♦ Rectocele ♦ Enterocele ♦ Rectal prolapse ♦ Treatment options for genital prolapse
  • Cesarean Section
    • ♦ Introduction to cesarean and elective cesarean birth ♦ History of the cesarean operation ♦ Risks of cesarean ♦ How cesarean should be performed ♦ Effects of cesarean on the newborn ♦ Ancillary benefits of cesarean birth
  • Summary and final comments
  • References
  • Glossary

The above changes coincided with a cultural revolution of numbing proportions. Whereas women usually delivered at home, attended by family members or a midwife, they now started to deliver in hospitals and clinics attended by doctors or highly qualified nurses and midwives. In most of the western world the midwife gave way to the family practitioner or specialist obstetrician. The home-like atmosphere of the childbirth experience changed into a fully "medicalized" event, with intravenous infusions, monitors, sterile packs, artificial bright lights, gowned physicians and restrictions on who might attend. The decisions to perform invasive procedures became the sole responsibility of the attending physician. Cesarean sections were performed increasingly for sometimes dubious indications, which lead to an inevitable and incredible rise in operative delivery rates.

To make the book more readable, I have simplified the anatomy of the normal pelvic floor and its disorders. The subject may be unfamiliar to the average reader and, in that sense, may prove difficult to follow. However, the illustrations will help the reader form a mental picture of the pelvic floor, which in turn will make the basic concepts clear, and that is what is really important. Some of the medical terminology may prove daunting, but is unfortunately essential. It would be more confusing to describe the pelvic floor and its disorders without the correct terms. Do not worry or be put off if a few of the more complicated explanations do not make sense. The main message and concepts will be clear. To explain every term when it first appears would interrupt the flow of thought in the text, so I have included a comprehensive glossary to explain each concept and term in detail. Writing a book to point out negative things that could, potentially, go wrong could be a morbid affair, but fortunately, this book is about more than that. It offers us a solution to the problem, and that solution is staring us in the face. My suggested solution is going to be a controversial one. My scientific facts are incontrovertible but the deductions and conclusions are my own and are open to debate. Others have expressed the same thoughts, albeit more cautiously, in scientific medical publications, and it has usually caused an uproar. Perhaps, in the near future new knowledge will enable us to predict which women are at risk for the disorders described here, and elective cesarean births could then be offered to the affected group alone. However, until then, we are compelled to work on the assumption that all women are at risk, and should at least be informed in order to make an empowered, personal, and calculated decision about childbirth. Let the debate begin!

I. Childbirth

The politics of childbirth:

Childbirth is such a fundamental and integral part of the human experience that its potential to create conflict is not surprising. Throughout the ages the policies and practices of childbirth have closely reflected the culture, political ethos and everyday experiences of the time.

"Any change looks terrible at first" 3

Cultural and political changes affect all aspects of human life and these invariably spilled over into the medical field and, specifically, the birth of a new life. During the 20th century the medical revolution not only changed the way we bring babies into the world, but even the very process of conception. These changes were, to a large degree, the result of key medical breakthroughs such as the discovery of microorganisms, antibiotics and improved fetal monitoring. The development of ways to monitor the intrauterine fetus brought about revolutionary change. Suddenly they were to patients to think about and the well-being of both were now the responsibility off the attendant. Conflicts arose between the well-being of the fetus versus that of the mother. Previously, interference for the fetus's sake posed such a hazard to the maternal well-being that the fetus was relegated to secondary status as nature was left to take its course, with often fatal consequences for the fetus. The improved operative vaginal delivery procedures, antibiotics, and more aseptic technique provided, for the first time, the ability to safely intervene to expedite delivery in some cases. The development of anesthetics and innovative surgical technique, coupled with potent antibiotics and sterile techniques, took obstetrics to a new label. Suddenly it was possible to deliver fetuses prior to the commencement of or at the very early stage of labor. As cesarean sections became safer and more standardized, the beneficial effects on labor outcome in many cases lead to increased usage, even to the point where it was sometimes done unnecessarily.

Because of the medico-political and healthcare-economic climate in most western countries today, patients are being denied knowledge and opportunities to make important healthcare choices. My hope is that, in the future, they will have the opportunity to make decisions based on what is important to them as individuals, and that they will not be coerced into decisions inspired by the political, feminist, or economic agendas of the day, or simply because it is the way it has been done in the past. Many will argue that women are making their own decisions, and that they prefer the "natural" way. My reply is that most women, currently, have inadequate information upon which to base their decisions. It is time that information about the pelvic floor be introduced into the equation.

I hope this book will make a useful contribution to the debate on this very important issue for women's health.

2. Lancet 1996, 347:544

Advances in labor and delivery:

Over the last few decades the practice of obstetrics, and especially the management of labor and delivery, has undergone tremendous change. Rapid technological and medical innovation has made labor and childbirth a medical event rather than a natural one. Over the last decade there has been a backlash, led by consumer and feminist groups, to resist this "medicalization" of childbirth. The medical establishment has followed this trend rather reluctantly, but in certain cases it has progressed as far as to institute programs which provide women the opportunity to be delivered of their babies at home. Hospitals too have changed their labor and delivery protocols to reflect this new attitude and try to provide a more homelike atmosphere. Patients and health-care providers alike offer frequent challenges to established protocols.

Patients have become more knowledgeable and assertive, and have access to a tremendous amount of knowledge. There are multiple lay publications on pregnancy, labor and delivery, and the Internet is a vast source of information. Unfortunately, information acquired from the Internet is of variable quality and not everyone has the knowledge to assess unsubstantiated and sometimes dangerously irresponsible opinions or statements.

I) CHILDBIRTH

Informed consent:

And underlying principal of good medicine is informed consent. Physicians have a duty to supply patients with the information necessary to make informed decisions regarding their medical care. Current knowledge makes it clear that vaginal childbirth can cause devastating pelvic floor damage with serious and long-lasting consequences to quality of life. Women often do not have enough information to empower them to participate actively in the decision-making process regarding their labor and delivery. These problems are rarely discussed or viewed as a compulsory part of routine prenatal care.

Currently most women are not given the option of elective cesarean birth. Perceptions, cost savings, availability and various other factors see to that. It is interesting to note that a recent survey in the United Kingdom found that one third of all female obstetricians polled indicated that they would choose elective cesarean birth, given the choice, specifically to protect their pelvic floor2. Eighty percent of those who indicated a preference for elective cesarean indicated that fear of the long-term consequences of a vaginal childbirth was the main reason for their preference. The main consequences feared included stress urinary incontinence and anal fecal incontinence (these problems will be explained in detail later). Further concerns included the effects of vaginal birth on their future sexuality and sexual function. A minority of these professional women indicated a concern for fetal health as their main reason for electing a cesarean. The telling responses of these knowledgeable women, more than anything else, convince me that a serious debate is overdue. If female obstetricians feel so strongly about the potential long-term negative effects of vaginal birth that they would increasingly choose elective cesarean births for themselves, the question needs to be asked: what are they telling their patients? Do they discuss this with their patients? I fear not.

As I have stated already, pelvic floor disorders are threatening the quality of life of millions of women worldwide. The motivation for writing this book lies in my sincere belief that something can be done to improve this disturbing situation. As with most things in life, unfortunately, there will be a price to pay.

"You always have to give up something you want for something you want more" 1

I believe that women should consider an elective cesarean birth as a possible solution. I certainly do not advocate that all women must undergo a cesarean section, but I do believe that it should bediscussedwith all women and that the information contained in these pages should be given serious consideration.

1. "Chris' comment": The Complete Murphy's Law; Arthur Bloch; P 7

CHILDBIRTH

Why this book is different:

You may well ask, "why another book about childbirth"? The field is so crowded that another book seems unnecessary, and I will agree that another general text on childbirth would make little sense.

I reassure you, however, that this book is unlike anything you have read before. Although it examines a small part of the childbirth experience, this small part is an aspect of immense importance and one that has been neglected up to now.

There are numerous excellent books that describe the pregnancy and birthing experience in detail, and that offer helpful hints and advice. They, however, focus on the immediate experience, namely, the miracles of pregnancy and of giving birth to a new life. They reassure the reader that childbirth is a natural process that usually ends happily with a healthy mother and child. Wonderful as this is, the process of vaginal childbirth has important implications that are brushed over or not discussed at all. This book is not about reassurances. It is about a problem that has been around forever, but which remains hidden and ignored even though it has assumed epidemic proportions.

In this book I will explore some of the changes that have occurred in childbirth philosophy over the years. The reasons for some of these changes will be discussed, to show how they were inspired not only by the desire to improve health, but by motives of political intrigue, by cultural influences and by territorial infighting. Some specific problems that may be encountered are discussed in detail, and the anatomy and functions of the pelvic floor are examined. However politically incorrect this may be, I believe that elective cesarean birth is currently the only proven way that a woman can protect her pelvic floor from the devastating effects of vaginal childbirth. This will not be achieved without a price, however, which will range from increased costs, both to the individual woman as well as to the health-care system, to surgical risks and loss of autonomy during the birthing process. Only by being informed about all the risks, as well as the implications of her decision, can a woman make an informed decision about the preferable way to have her baby. The decisions taken are too often a result of peer or group pressure about the way it is supposed to be done. I wish to expose the flaws of this type of thinking, and will feel immense satisfaction if this book helps women take control of their birthing experience and the decision about how to have the baby - be it by vaginal or cesarean birth. Knowledge about the implications of either decision is essential if a woman is to make not only an informed decision, but also her own decision. I can hope for nothing more. To make the book more readable, I have simplified the anatomy of the normal pelvic floor and its disorders. The subject may be unfamiliar to the average reader and, in that sense, may prove difficult to follow. However, the illustrations will help the reader form a mental picture of the pelvic floor, which in turn will make the basic concepts clear, and that is what is really important. Some of the medical terminology may prove daunting, but is unfortunately essential. It would be more confusing to describe the pelvic floor and its disorders without the correct terms. Do not worry or be put off if a few of the more complicated explanations do not make sense. The main message and concepts will be clear. To explain every term when it first appears would interrupt the flow of thought in the text, so I have included a comprehensive glossary to explain each concept and term in detail.

I) CHILDBIRTH

Culture in childbirth:

The influence of culture on the experience of childbirth both individually as well as in the broader social context of the community should never be discounted. The whole experience will be painted with communal characteristics for instance exhibitionism versus a more private experience, the expectation and reaction to the pain of childbirth, as well as the satisfaction with specific support mechanisms and gender of the newborn infant.

A vivid example of the role of culture in childbirth was an experience I had as a medical student. I spent some time at a missionary hospital near in what was then the Venda region of northern South Africa. The maternity department of this rural hospital (Tshilidzini hospital) was extremely busy and delivered a large number of babies every day. Two tribes made use of the hospital, namely, the Venda and the Shangaan. The labor-and-delivery area was divided in two, thus separating the two tribes. This arrangement was not the result of the politics of the day, but as I came to understand, arose for a very practical reason.

The Venda side was filled with screaming and thrashing women, while on the Shangani side one could literally hear a pin drop. Strange as this may sound, it was the exclusive result of cultural differences. It was explained to me that the more pain and suffering Venda women endure and express during childbirth, the larger the presents their husbands have to buy. On the other hand, in the Shangani culture, to make a scene during childbirth brings disgrace upon the mother.

Another example of such cultural influences on childbirth is the difference between the usual Western Caucasian experience and that of the native peoples of the British Columbian Pacific Northwest. In the typical Western model, one or two assistants are the norm for a typical labor and delivery. Until not too long ago, fathers were not even expected to be there. The usual situation these days, however, is for the father to attend throughout labor and delivery, and he has become an integral part of the experience. The mother is often assisted by a professional Doula (labor support person), a friend or other relative. In contrast, my personal experience with the Pacific Northwest first nation's culture was that childbirth was an extended family affair, almost a community event. Aunts, uncles, brothers and sisters, even cousins, nephews and nieces would often attend, making it quite the gathering. When I first arrived in British Columbia and started working in Prince Rupert, quite initially felt it quite disconcerting to have so many people in the hospital delivery unit and just outside the door. Except in cases of abnormal labor, when stricter rules were applied, I came to appreciate the value of all this excited distraction, which prevented the laboring woman from focusing on her contractions.

The money factor:

Change is inevitable and it is well known that change often brings conflict. Such different professional groups as family practitioners, obstetricians and midwives often pit themselves against one another with conflicting interests. Governments and health maintenance organizations are increasingly involved in the active management of healthcare and maternity care. Not only do they often developed different fee schedules, which causes resentment, but they actively encourage and often force patients into specific channels or modes of care, and the reduction of cesarean section rates is very high on their agenda. Their involvement should be viewed with suspicion, as their main interest is an economic one:

"1. No matter what they're telling you, they're not telling you the whole truth.
2. No matter what they're talking about, they're talking about money." 
9

Government studies usually focus on population outcomes and global costs. After all, the individual patient's situation does not hold much importance, for governments, in the global scheme of things. Likewise, costs that might be incurred many years down the line are not considered. Instead, with their short-term thinking they consider only the direct costs of, in this case, vaginal versus cesarean section birth, and vaginal birth is clearly the cheaper of the two. Yet, there are over 400,000 operations per year in the United States for genital prolapse alone, most of which can be directly related to vaginal childbirth. This number is certainly likely to take a significant leap in the very near future as the baby boomer generation ages. No study that I am aware of as ever taken this into consideration when it compiled cost differences. Loss of economic activity in those who are seriously affected by pelvic floor damage from vaginal birth, and in those who are recovering from their corrective surgery, is also not considered.

9."Todd's two political principles": The Complete Murphy's Law; Arthur Bloch; P75

Demographics:

Women are having fewer and fewer children, and are having them later in life. The current mean for Canadian couples is between 1.5 and 1.6, which is below replacement numbers. In fact the birthrate is currently below replacement numbers in 10 first world countries. The rapid increase in the elderly population in the first world is juxtaposed against a dramatically falling birthrate. In 10 years from now there will be 15 people above 65 for every one child born. The medical profession is certainly not prepared for this "sea change" in demographic reality with its financial and social implications.10

Another trend is that of having the first baby later in life. Couples also frequently know exactly how many children they plan to have (not many) and undergo permanent contraceptive methods when they reach their target. These statistics are actually quite frightening if one thinks about the socio-economic implications of the rapidly decreasing birthrate of the Western world. It has been said that Southern Europe is committing
collective suicide with a birthrate of less than one child per woman of reproductive age. Italy currently has approximately 60 million people, but current birthrates indicate that there might be only about 20 million at the end of the next century.

There is a direct correlation between affluence and diminishing numbers of children, but a new factor now threatens to create a vicious cycle. Young people will be compelled to make direct financial outlays, or, indirect outlays in the form of higher taxes, to support the growing numbers of needy seniors with increasing health-care needs. An inevitable result of this financial burden on tomorrow's young people will be a potential further reduction in the number of children.

As a result of this current and future drop in fecundity (number of children), the negative effect of cesarean section for repetitive pregnancies and future births is thus significantly reduced. This, however, is one of the main reasons that is usually cited for the need to reduce cesarean section rates. It goes without saying that there is a major difference between women, who plan their pregnancies and know how many children they want,and those who either do not know, do not care or who know that they want many children. For this latter group, the higher risk of subsequent and multiple operations, and the inherent risks of the scarred uterus for future pregnancies, will outweigh many of the benefits of elective cesarean births. As shown, this group is becoming a minority and is likely to remain so for the foreseeable future. This book is thus aimed mainly at the large numbers of women who probably have postponed their first pregnancy, and who know exactly where they want to go as far as their reproductive careers are concerned.

Women today can expect to live a major portion of their lives after they have finished their childbearing. Life expectancy in the western world is the highest it has ever been in human history, and it is still climbing. It can be expected that, in the near future, widely anticipated medical and genetic breakthroughs will increase the human lifespan significantly. Consequently, and because of the decreased birthrate, the effective time that women in the western world spend being pregnant, as a percentage of their lifespan, is the lowest it has ever been. Any negative effect of childbirth on a woman's future, in quality of life terms, is thus more important today than it has ever been in history.

Women live more active lives with increasing participation in sports, business and all walks of life into old age. Urinary and fecal incontinence could, today, result not only in inconvenience, but also in disaster in terms of quality of life. Where as in the past women usually suffered these symptoms in embarrassed silence, they rightly do not put up with it anymore. Unfortunately for them it often means major, sometimes repetitive and expensive surgery with no guarantees of success.

As a result of the above demographic and lifestyle changes, as well as future increasing public knowledge about the pelvic floor and the effects of vaginal childbirth on its components, I believe that the drive to reduce cesarean section rates will fail in the long-term. The protection of the pelvic floor is destined to become a major indication for elective cesarean births in the very near future. It is interesting to note that the pendulum
has begun to swing back, albeit slowly, as regards electing vaginal birthafterprevious cesarean section. After a decade of intense interest and tremendous push for vaginal birth after previous cesarean, some authorities, including the American College of Obstetricians and Gynecologists, have started to express concern about the almost blasé attitude of many caregivers towards these patients. Medico-legal concerns might soon make VBAC (vaginal birth after cesarean) a thing of the past except in large tertiary hospitals with on site, immediately available cesarean section coverage.

10."The aging male: Why should we be concerned?": Prof Bruno Lunenfeld: Andrology in the Nineties International Symposium on Human Sub-Fertility. 24 March 1999 Cape Town, South Africa

Your physician's dilemma:

It is unfortunately true that there is always the possibility of complications or side effects with any medical treatment or management. To keep these unfortunate outcomes to a minimum, choices should exclusively be dictated by good science which leads to evidence based decisions and recommendations by the healthcare provider. The other part of the equation should be the process of autonomous patient decision-making, based
on informed consent, as already discussed. Although it is necessary for ministry of health or health maintenance organization bean counters to look at the global costs of different management protocols, as a practicing physician, I do not believe that it is correct to let cost issues alone dictate the care I suggest to the individual patient. This of course leads to conflict, since physicians are constantly bombarded and squeezed by reduced health care dollars, fewer hospital beds and administrators concerned with the bottom-line. The specifics differ from country to country but the refrain remains the same. The patient's financial means and specific situation must of course be taken into consideration as well when suggestions are offered.

Physicians do have a responsibility to the community at-large in terms of cost effective healthcare. First and foremost, however, my primary responsibility is to my patient and the best possible care that I can provide or organize, based on that patient's individual problem and situation. Most importantly, my relationship with my patient should be based on mutual respect, trust and a complete understanding on both sides of all the issues involved.

This is where informed consent is so crucial. As the physician, I must be informed about the patient's particular circumstances and wishes. It would be inappropriate to suggest management options that are clearly against the patient's wishes or freedom to consider at that point in their life. It might be only a question of further explanation and enough time for the patient to come to grips with the reality of a particular situation before some invasive medical procedure is suggested. It might be a question of affordability or lifestyle that would preclude certain actions. My point is that the physician should individualize the treatment to the particular patient. The patient must be fully informed about the different therapeutic optionsandthe specifics (risks versus benefits) of each option. This would include the expected outcome, possible side effects and complications as well as the possibility of total failure. The patient's responsibilities include supplying the necessary information to allow the physician to decide on appropriate options and making sure that she understands clearly the implications of what the physician is saying. Eventually this relationship should culminate in a patient confidently making the final decisions.

Although we try our best, I believe that there is one area of modern obstetric care where we, as the supposed leaders, fail dismally. Although physicians have known for a very long time that childbirth and, specifically, vaginal childbirth often leads to significant maternal injury, this knowledge is seldom communicated to patients. This is partly due to time constraints. As a practicing OB/GYN, I find myself lacking time to do justice to the principal of informed consent. The exponential increasing in our knowledge means that more and more things need to be discussed with our patients. More and more options with equal chances of success, but with more potential side effects and complications, need to be taken into consideration and, of course, these options then need to be discussed in detail. Physicians are increasingly placed in the position where they have to decide which options are important to communicate and which not. It can be argued that this has always been their role, but that is to dismiss the problem too lightly. Litigation against doctors, which involves multi-million dollar claims, is a relatively new thing, but it is increasingly common. It is also now common for patients to visit their doctors with a stack of printouts from the Internet, and they expect that their physician will discuss the merits of all this information with them. We take a keen interest in television programs like the Oprah Winfrey show, because after each show that deals with medical topics, physicians are bombarded and challenged by patients who have soaked up every word. Unfortunately some doctors have become defensive in order to try and safeguard themselves. This has introduced an element of mistrust into the doctor-patient relationship. The giving of information to the patient changes from an education process, with the best interests of the patient as the motivation, to physician self-preservation, or an effort to prove that the physician is an authority in an increasingly complicated situation. The result is that most physicians are loath to discuss new ideas with patients, especially ones that are not currently in the medical mainstream. Of course this is a generalization, but unfortunately true, I would dare say, of many doctor-patient relationships in the Western world today.

A silent epidemic:

The fact that there is a high risk of pelvic floor injury during childbirth has been known for a very long time. Many medical articles have been written about this since the early part of the 20th century. Over the last decade there has been a virtual explosion of scientific articles published in respected obstetrical journals regarding this problem. Congresses are held to compare notes and the newest research into the area, and ways to prevent pelvic floor damage are debated. It is therefore shocking and surprising that while the academic community is debating the various issues, the level of knowledge about this problem is so low in the general public. There are no lay books on the topic and, most disturbing to me, is the almost total disregard of this problem in the current crop of respected "pregnancy and childbirth books". Therefore, despite academic acceptance, it is still in reality a "silent epidemic".

In the next section we will examine the pelvic floor itself and its integral role in childbirth. We will explore the possible effects of birth on the health of this extremely important structure and follow the natural progression of pelvic floor disorders. The more common pelvic floor disorders will be described in detail. Finally the actual facts of cesarean birth will be examined closely. Not only will the technical aspects and benefits of this birthing method be addressed, but also the possible risks and complications for the mother and the newborn baby alike.

II. The Pelvic Floor

"Research scientists are so wrapped up in their own narrow endeavors that they cannot possibly see the whole picture of anything, including their own research." 11

Why the pelvic floor has been neglected:

The pelvic floor is one of the most neglected parts of the human body. Its function is unseen and therefore largely unappreciated, and it is treated as somewhat embarrassing, definitely an unfit topic for polite conversation. The various disorders caused by pelvic floor damage or dysfunction are extremely embarrassing problems that women do not easily discussed with their physicians and even less with their friends. Consequently, these disorders were not taken seriously and did not generate much influence or interest in the medical community. Compartmentalized medical specialties have also led to the neglect and fragmentation of research into this structure.

The realization of the role the pelvic floor plays in some of our most intimate daily human activities is fortunately changing the situation for the better. Even so, we still have many more questions than answers. To this date, it is mostly unpredictable which women will develop the disorders discussed in this book. The main scientific debate is currently focused on the roles of the various muscles, ligaments and supportive tissues, as well as possible neurological damage, as causes of pelvic floor disorders. It is my firm belief that all these factors do play a role and that it is necessary to look at all of them to find cures or preventative measures.

11."Whole picture principal": The Complete Murphy's Law; Arthur Bloch; P126

Attributes of the pelvic floor:

Support:

The pelvic floor is exactly what its name applies. Basically, it is a floor and, specifically, it is the floor of the pelvis. It is not only the floor of the pelvic organs, however, but in truth, of the whole intra-abdominal cavity and all its organs. Like any floor, the pelvic floor provides support and keeps everything above it in its proper place. Without this foundation, the intra-abdominal organs have nothing to keep them in place and they would simply fall through the pelvis.

The pelvic contents, which are in close and intimate relationship with the female pelvic floor, include the uterus (womb), bladder, rectum and sigmoid colon (part of the large bowel). The rest of the intra-abdominal organs, for instance, the rest of the bowel, lie on top of the above organs and thus use them for support. Supporting all of these is then one of the duties of the pelvic floor.

Dynamic involvement in bodily functions:

The pelvic floor is, however, more important than a mere support organ. It is not by nature a passive support structure, as its name would imply, and it is not an unyielding platform. In reality this organ is a tremendously fascinating, active, and vital structure. It plays a direct, active, integrated and essential part in childbirth, urination, defecation and sexual function. It is essential to the maintenance of urinary and fecal continence; that means it helps in the maintenance of the integrity of the bladder and rectal storage mechanisms, and in the prevention of inadvertent wetting or soiling. During urination or defecation the role changes from support and the facilitation of continence, to an active and important contribution to these activities. It permits the expansion of, for instance, the lower rectum to allow the passing of feces. For urination, relaxation of the pelvic floor allows the descent of the bladder neck, which causes a funneling of the upper urethra, which helps to initiate urine flow. The muscles of the pelvic floor play a role in the amazingly intricate control people have over their bowel movements. Not only does it allow gas to escape while it maintains continence of solid and fluid fecal material, but the timing of such relief is under its direct voluntary control in the normal and usual situation.

Safety net:
An intact pelvic floor prevents prolapse of the pelvic organs into the vagina. Most importantly, it prevents a downward bulging of the bladder, an upward bulging of the lower rectum and helps to prevent the uterus from falling through the vagina. It is especially while straining during urination or defecation that the tendency for these organs to bulge into the vagina becomes severe, and it is basically only an intact pelvic floor which can prevent that from happening.

Sexuality:
I do not think anybody can dispute that sexuality is one of the most important life forces. Not only are positive sexual experiences some of the most pleasurable of human sensations, but continued enjoyable sexual relations form the bedrock of long-term relationships as well as a healthy and positive self image during one's life. A normal and intact pelvic floor is important for optimal sexual function.

During intercourse, the muscles of the pelvic floor play a major role in orgasm. The contractions of these muscles in the female is also important to provide a tighter vaginal grip on the penetrating penis, which facilitates male and female pleasuring. During orgasm the pelvic floor muscles contract in rhythmic waves, which is the main reason for the pulsating nature of any orgasm.

Pelvic floor damage in the sexual context is commonly known as a "stretched" or "lax" vagina. Although this is seldom presented to their physicians as a problem, for obvious reasons, specific questioning of such women and their partners often reveals some dissatisfaction with their sexual lives. It is of course not purely the size of the vaginal aperture which matters, just as the size of the penis is not the most important thing, but the problem is often with discomfort associated with genital prolapse or even incontinence during intercourse. I want to quote from a letter published in the Canadian medical newspaper "The Medical Post" dated the 19th January 1999"

"It could hardly be more apparent that, when a large mass - the fetal head - is forced irresistibly through a constricted very narrow channel - the vagina - and a much more restricted outlet - the vulva - it cannot help but to disrupt the fascial supports of bladder, urethra and rectum in the former, and, on emergence, tear its way through the latter. Unassisted by intelligent intervention to reduce the otherwise certain damage of vaginal overstretching with laceration of fascial support to bladder, urethra and rectum and gross relaxation of the vulva, delivery will have two almost inevitable results: marked vaginal enlargement and vulvar relaxation, with permanent loss of marital interest in both partners; and, after 20 or more years, the almost certain need for reparative surgery to correct uncontrollable urinary dysfunction".

Although this personal opinion can be criticized for being somewhat overly melodramatic, it drives home in a graphic way one of the prime messages of this book.

In summary then, certain pelvic floor defects can lead to a failure of its various functions. This could involve the prolapse (falling into; or falling out) of different organs, which can be severely symptomatic to the point where it disables the person. This could lead to symptoms, which include urinary or fecal leakage, constipation, pelvic or back discomfort and pain, and paradoxically sometimes even the inability to pass urine or bowel movements. Enlarged vaginal aperture in the setting of weak pelvic floor muscles can also lead to sexual dysfunction and dissatisfaction. Further pelvic floor dysfunctions, which will not receive much attention in this book, include disorders such as vaginismus and vulvodynia, which are also often related to psychosomatic disorders, sometimes traumatic and painful childbirth experiences or possibly resulting from previous sexual abuse experiences.

II. The Pelvic Floor

Evolution and childbirth:

My pastor recently asked me whether or not I believed in evolution. This was during a more general discussion involving religious and denominational problems at my house. At the time, as a result of the way it was worded, I suspected that I was being set up - a test of faith - so to speak. Since I was unprepared for the question and had not given the matter any thought for a very long time, I mumbled a somewhat incoherent response that didn't satisfy either of us. The question however stimulated me to embark on a quest for knowledge on this, as it turned out, extremely interesting topic, partially to satisfy myself, but also because I immediately saw the relevance to this manuscript.

My research culminated in an opportunity to examine the skull of an Australopithecus robustus specimen as well as the pelvis and skeleton of an Australopithecus africanus that are estimated to be 2.5 million years old (personal communication with Dr. Ina Plug and Dr. Francis Thackeray of the Transvaal Museum). These fossils were found in one of the most productive areas for Australopithecine fossils namely Sterkfontein and Swartkrans in the Krugersdorp districts of South Africa. My opportunity to handle the fossils occurred in March 1999 in the Transvaal Museum's department of Anthropology in South Africa. Actually holding these skeletons in my hands made a very big impression on me as well as my thoughts about human ancestry.

I found the 2.5 million yr. old pelvis especially interesting. That of an adult, it was quite small - the individual was just over four feet tall, but was unquestionably that of a bipedal hominid. The wide bony pelvis looked strikingly similar to that of the modern human. Internal bony structures (determined by modern scanning methods) confirm bipedalism and the resultant particular muscle action found only under such conditions. Muscle action leads to molding of bone as a result of bone turnover and the formation of stress lines in relation to the direction of the muscle action. These lines can be determined by scanning methods and it is thus possible to determine exactly how, and in which direction, muscles operated in the living individual. The pelvic inlet looked perfectly gynecoid (like that of a modern female human) with a normal pelvic inlet as well as outlet.

A few obvious facts flow from these observations. Firstly, this individual walked upright, and probably had the same or basically the same pelvic muscle action as modern humans. Secondly, the shape of the pelvis suggests that the birthing process was similar to that of the modern human.

The earliest fossil records of a hominid bipedal (human-like and walking upright) can be dated to about 3.5 million years ago. This species, called Australo- pithecines, had an almost human-shaped pelvis, but a much smaller brain capacity. There are numerous theories to explain the evolutionary benefit of the erect posture that ultimately contributed to the hominid species becoming the dominant species on the planet. One of the most logical theories is that by freeing the hands for purposeful manipulation of tools, the hominid gained an increased ability to defend itself and to acquire food. These factors may have led to an increased evolutionary fitness in terms of competition with other species, possibly partially because of intellectual development, that flowed from and became the almost inevitable result of the increasing "free time" of the hominid arms and hands.

Various evolutionary processes, for instance the above mentioned increasingly complex, manual manipulations requiring fine neural control, as well as the development of speech, theoretically led to a massive increase in brain capacity to sometimes more than 2000 ml. (average for modern human is in the order of 1400 ml.) This increase in brain capacity is well documented in the fossil records with a direct line that can be drawn from Australopithecus, through Homo habilis and Homo erectus to Homo sapiens sapiens (us).

One theory has Homo sapiens sapiens and another species, called Homo sapiens neanderthalensis, coexisting until as recently as 30,000 years ago. According to some the two species did not interbreed and Homo sapiens neanderthalensis might have become extinct as a result of direct competition with Homo sapiens sapiens. Interestingly Homo sapiens neanderthalensis had a brain capacity that rivals (and sometimes exceeds) that of the modern human. There are tremendous differences in opinion about the ultimate fate of this interesting species and the debate makes for fascinating reading.

Another viewpoint is that most, if not all, bipedal ancestral hominids, were in fact, "human", with religion, speech, music and compassion. This theory is argued using some evidence from various paleontological and archeological findings, and the presence of distinct impressions inside the skulls of some of these fossil-men which means that they possessed the brain structures called Broca's and Werniche's areas. These refer to the areas of the human brain responsible for and essential to, speech. Although new research has shown that the processing and interpretation of speech occurs much more widespread throughout the brain than previously believed, these two areas are definitely crucial. If one accepts that these fossil-men had spoken language, had religion, compassion and made music, the only logical deduction is that they were self-conscious beings and thus must have been human, however primitive. The term "human" is however surprisingly problematic. We are so used to seeing ourselves in total isolation from the rest of nature that a glimpse of our real place in nature comes as a revelation (not necessarily a pleasant one).

To see some of these fossils as "human" does not necessarily imply ancestral relationship to Homo sapiens sapiens. Many authorities believe in the existence of genetically distinct bipedal or Homo species that might have become extinct without having been ancestral to us. Examples like the Neanderthals possibly split from the ancestral line at some point in the distant past and became distinct but ultimately unsuccessful species in their own right. Most of the known fossil hominids like habilis and erectus were however almost certainly ancestral to us.

Bipedalism (walking upright on two legs) is quite an unusual development, as any superficial observation of the animal kingdom will confirm. With the benefits of bipedalism came certain problems, for instance, the all too common problem of lower back pain, which is one of the weakest areas of our bodies. Another problem was the size of the pelvis. A balance had to be found between a more efficient, thus narrower pelvis (the faster you could run, the more likely you were to survive) and a pelvis of adequate size to allow birth. This point is well illustrated by comparing the increased efficiency of the various muscles implanted in the male pelvis in comparison to the female pelvis. This balance between efficiency and adequacy was a critical development in human evolution and led to what I would call the "mechanical imperative".

Another theory that tries to explain the increased evolutionary fitness of Homo sapiens is the development of speech, which made communication and the development of culture possible. Whether one believes in Divine Creation or materialistic/naturalistic evolutionary theory, it is clear that humans have exceptionally large brains, which is the main reason for our tremendous success as a species. This success is amplified by the reality of the fact that we are truly newcomers to this planet. This is very graphically illustrated in the Museum of Natural History in San Francisco and many others. On a comparative timetable from the Jurassic period onward (during which dinosaurs ruled the world), our residence on this planet hardly shows at all. Our large brains come with a price however, which we will now discuss.

The large brains that humans have and our necessarily big skulls create significant problems for the birthing process, in that the fetus survives best if it is large, but this has obvious consequences for the mother. The birthing process can be likened to a competitive interaction between the mother and her fetus, with some common ideals (such as the survival of both), but also some divergent goals; namely, to personally emerge from the experience in as good a shape as possible.

Recent evidence from scientific studies has indicated the possibility that the pregnant mother can directly influence the size of her unborn fetus, especially towards the end of her pregnancy. It has been shown that this observation holds true even in the setting of donor embryos from larger genetic parents into smaller surrogate mothers, who deliver smaller infants than might have been suspected. The theoretical way the birth mother can accomplish this is by restricting the bloodflow to her uterus and thus the availability of nutrients to the fetus.

This finding may be evidence of the mother's attempt to protect her own interests to the general detriment of the fetus. Of course it should be self-evident that if there were an insurmountable discrepancy between the pelvis of the mother and the size of the fetus, it would also pose a clear disadvantage for the infant. This "mechanical imperative" may explain the relative underdevelopment (altriciality) of the human newborn infant compared to most other primates. Gestational restriction (that is, restriction of time for growth) is essential to permit human birth. The human newborn has been called an "extragestational fetus", which means that it still has fetal qualities but now has to survive outside the uterus. It also implies that, if not for the mechanical pelvic "imperative", human gestation might have been much longer. This comparative underdevelopment of the human newborn obviously required the development of strong social groups to share the tasks necessary for survival.

Certain theoretical advantages have been attributed to this "premature" birth of the human fetus. In comparison to other primate species, for instance gorillas and chimpanzees, the human newborn's brain, although bigger, is less developed in relation to the final adult brain. Now, everybody knows that the first few years of a child's life are critical for the formation not only of personality, but also of brain development and intelligence. The human infant, because of its early birth, is exposed to and bombarded with all the stimuli and brain-forming sensory inputs that its now "extra-uterine" world provides. In contrast, at a relatively speaking similar developmental level, the small gorilla and chimpanzee fetus, sensory deprived, is still wallowing in its amniotic fluid while its brain develops further with only genetic input.

One further ingenious development in the human birth process was the advent of the rotation of the fetus as it moves down the birth canal. At any given time the longest axis of the presenting part of the fetus (usually the head), has to fit in the corresponding axis of the pelvis. Since the human female pelvis is widest transversely at the entrance and widest longitudinally at the exit, the fetus has to rotate. Non-rotation is a common reason for failure to progress in labor and the subsequent emergency cesarean. There is some debate about whether this feature, which is a characteristic and essential element of human birth, was also present in fossil-man (or rather – woman). After my personal meeting with just such an individual, I believe that it was.

Evolutionary theory purports that "reproductively unfit" mothers, with pelvises too small to give birth, would die during childbirth and thus not propagate their (or their partner's) genes (the baby would almost always die as well). The other side of the coin is that the inability of babies with increasing brain size to be born alive, theoretically inhibited any further evolutionary brain size development.

Our ability to deliver babies safely by cesarean section in cases of obstructed labor has revolutionized our ability to intervene in nature. This ability has not only removed the necessity for an adequate pelvis, but also the impediment to possible further evolutionary brain-size development. The question has been asked whether evolution as a species shaping force, is still active in humans. As a result of our intellectual ability to subject nature to our collective will, many of the selection pressures of the Darwinian model isn't valid in our species anymore. By safely delivering and helping babies who would otherwise have died to survive, we have escaped the tyranny of raw natural selection. This is not only the result of modern medicine of course. Our whole society has a role to play here. Whether selection still plays a subtle role in the human race however, is an interesting question with no definite answer. This is furthermore true since a lot of detail about precisely how evolution operates is still being worked out. In his book "Genes, Genesis and God", Holmes Rolston proves philosophically that cultural evolutionary forces is currently the more dominant force in human evolvement and becoming.

The upright posture of humans brings with it a number of other problems. When we look around the animal kingdom, we find in most mammals that the pelvic " floor" is not a floor at all, but a wall. Since the usual primate posture for the body is mostly horizontal, the brunt of the intra-abdominal weight does not continuously fall on this structure, but rather onto the anterior abdominal wall. In the human, the pelvic floor became the most important support structure for the pelvic and abdominal contents. The pelvic floor counteracts the full force of gravity and with weak pelvic floor muscles, the fascial layers (to be discussed later in detail) are the last defense against prolapse.

In nature's scheme of things, the integrity of the pelvic floor over time is, after all, not all that important. By the time pelvic floor disorders become significant problems the most important biological functions, which ensure the survival of our species (namely, reproduction), have been completed. Further, since these disorders usually lead to a personal loss of quality of life rather than decreased life expectancy, they have had no discernable influence on the course of evolutionary development. For most of human history people rarely survived to an age where it did become a problem. Fortunately this has changed dramatically. It is imperative for us to look with new eyes at this problem and to develop new strategies to protect those parts of our bodies less likely to stand the test of time and aging.

"Our remedies oft in ourselves do lie
which we ascribe to heaven: the fated sky
Gives us free scope; only doth backward pull
Our slow designs when we ourselves are dull."


--Shakespeare, All's Well that Ends Well

I am now in a better position to answer the Pastor's question. "Do you believe in evolution?" I want to begin by asking the Pastor a question. Do you believe in chemistry?

The answer is complex. One doesn't have to believe in it in an ordinary sense. Chemistry is science and as such is a product of the scientific model. This model can be defined as follows. Science mostly depends on testing predictions that are logically derived from hypotheses. Greater and greater confidence is achieved in the validity of the hypotheses as more and more data support or fail to refute them. These hypotheses have to be refutable (that is you have to be able to think of circumstances that could nullify the starting hypotheses). No belief system is required; the processes can either be observed or tested. Nothing is ever completely "proven" in science. The hypotheses however become more and more accepted as the data correspond and become overwhelmingly in its favor.

All of the above is absolutely true of evolution. Thus I do not have to believe in evolution. It is science - and as a result of the overwhelming weight of data accumulated since the time of thinkers like Comte de Buffon (1707 –1788), Immanuel Kant (1724 –1804), Pierre-Simon Laplace (1749 – 1827), James Hutton (1726 – 1797), Carolus Linnaeus (1707 – 1778), Chevalier de Lamarck (1744 – 1829), Charles Darwin (1809 –1882), and innumerable others, has now become fact; science fact. Not one of the above or most other naturalists had as their goal a challenge to the orthodox religion of their time. They practiced science, pure and simple. Unfortunately it sometimes (as still happens today) brought some of them into conflict with set religious ideas and interpretations.

"It is time for students of the evolutionary process, especially those who have been misquoted and used by the creationists, to state clearly that evolution is fact, not theory….Birds arose from nonbirds and humans from nonhumans. No person who pretends to any understanding of the natural world can deny these facts any more than she or he can deny that the earth is round, rotates on its axis, and revolves around the sun." Richard C. Lewontin, 198112

Religion is not necessarily opposed to evolution. For instance the Roman Catholic Church called it an important scientific question worthy of further research. (More information is available on the Internet). The best book defending this view I read is: "Theology for a Scientific Age; Being and Becoming – Natural, Divine, and Human" by Arthur Peacocke.

Whatever view one holds however, one cannot escape the fact that the delivery of a healthy infant, without significant damage to the mother, is a high stakes competitive and astonishingly finely balanced process. This same process is responsible for our survival as a species, but things can (and do sometimes) go wrong.

12. Richard C. Lewontin, who holds the Alezander Agassiz professorship at Harvard University, is a leader in research on the genetic basis of evolution.

II. The Pelvic Floor

Understanding the Pelvic Floor:

The easiest way to visualize the pelvic floor is to imagine a trampoline (see illustration). Think of one of those small round framed trampolines found in many neighborhood gardens. Now, imagine this trampoline's frame to be slightly bent, so that it is somewhat wider from side to side than from front to back. Imagine that it is bent a second time, so that the front end is slightly more pointed than the back, and that the black canvas (webbing) is somewhat sagging. Now picture three holes cut into the canvas one behind the other, in the fore and aft plane. The front hole is the smallest. The other two holes behind it are almost equal in size to one another and a bit larger than the little one in front. Got it so far? Our pelvic floor picture is almost complete, but a few details still have to be sketched.

Now imagine a sling made of car seat-belt material sutured onto the canvas and looping around all three holes. It originates just off-center on each side of the front of the trampoline frame where it is strongly attached. This seat belt loop is tightened so as to pull the canvas slightly forward and in the process closes the holes in it off.

Lastly, imagine a piece of very strong white sheet on top of the black trampoline canvas. This sheet is sewn onto the canvas, but is only attached to the frame at the front. Along the rest of the way it is attached to the canvas, especially on the sides. The same holes cut into the canvas permeate the white sheet.

trampoline

This, very simply, is the pelvic floor. The trampoline frame represents the pelvic bones and the black canvas the pelvic floor muscles. The white sheet represents the pelvic fascia, which will be discussed and explained later, and the sling represents the puborectalis part of the pubococcygeus muscle (don't worry, we'll get to it). The three holes represent the openings where the pelvic floor is penetrated by three tubular structures, namely, the urethra, vagina and rectum, in that order.

The pelvic floor is not really horizontal or even flat. Instead, the muscles usually form a concave shape, just like our imaginary loose canvas, but since it is an active organ it can also contract to a convex shape, thus creating active lift.

The most important muscles include the pubococcygeus, iliococcygeus, coccygeus and ischiococcygeus muscles that together form the levator ani muscles (one each side meeting in the midline). Although considered different muscles, they form a single unit in one plane and function in unity. The levator ani are mostly made up of fibers of the so-called slow-twitch type. Such muscles are designed to provide constant and prolonged contraction even though the person is not aware of it. They do not tire easily and, unlike ordinary skeletal muscle, they are able to provide constant support. We are usually not conscious of them, which is somewhat different than most other skeletal muscles, but they are, however, also under our voluntary control. This is mainly because they also contain so-called fast-twitch fibers. These allow quick responses to messages from the brain during episodes of involuntary and increased intraabdominal pressure, as occurs when we cough, sneeze, or laugh. The resultant contraction then serves to counteract the downward pressure that is generated.

There are a few other muscles we should be familiar with if pelvic floor defects are to be understood. These are the various sphincter (clamping) muscles of the tubular hollow organs perforating the pelvic floor and whose dysfunction may cause fecal or urinary incontinence (leakage). Although much more complex than the descriptions here, the main point to understand is that both the bladder neck as well as the lower rectum have strong sphincter muscles that are under voluntary control. This control is needed to overcome those sudden urges we all know, to urinate, to pass gas or to defecate at inappropriate times or under unacceptable circumstances. The sphincter muscles can also contract reflexively, however, to counteract involuntary episodes of increased intraabdominal pressure. It is obvious that the weakness caused by direct damage to the muscle tissue itself or to its nervous supply will lead to poor function and to the danger of incontinence.

Everyone is aware, at least, of his or her rectal sphincter muscles. If one does not actively relax this sphincter, one just cannot defecate. The flip side is immediately obvious. If the rectal sphincter relaxes when it should not, or if it cannot contract or maintain the necessary tonic contraction, involuntary defecation or incontinence is a high probability. Sphincter muscles are in effect our safety clamps. They give us control over our bodily functions, and without them we would be at the mercy of every bowel and bladder contraction. This would have made civilization, as we know it, impossible.

I worked for a few months as a medical officer in the Kaokoland of northwestern Namibia (then called "South-West Africa"). This is the traditional area of the Himba tribe. The Himba are, to this day, one of the most isolated nomadic peoples in the world. They wear basically only loincloths, beads and a mixture of fat and clay, which they paint on their bodies. They wash only a few times a year, accompanied by celebrations, and because they are nomadic, they possess few belongings. Most of their rituals and habits are easy to appreciate as very appropriate and practical adaptations to a very harsh environment. The Kaokoland is an extremely dry and desolate region. During the few rainy months, when very little rain actually falls, malaria is rampant. Fresh water for washing is not available for most of the year, and the fat and clay effectively keeps the mosquitoes at bay. The two things that I remember most about the Himba people, however, are the following: They are a fiercely proud people, distinguished by their erect bearing and aura of great dignity. There was no question of embarrassment about their almost naked bodies. The first thing usually done by hospital staff after Himba people were admitted to hospital was to wash off from their bodies the rancid mixture of fat and clay. This was necessary of course to preserve conditions of asepsis, but also the white hospital linen. Immediately after this washing, however, the women (whom I usually treated) felt suddenly shy and felt naked. My second distinct memory was the tribe's completely uninhibited attitude to normal bodily functions. I vividly remember groups of Himba women walking in the town of Opuwo, who would suddenly stop, spread their legs and urinate in the middle of the street before walking on as if nothing untoward had happened.

Our western sensibilities and culture find this behavior almost incomprehensible, but this example illustrates how much our attitudes and taboos about bodily functions, have helped to shape our civilization and cultural psyche. It is interesting to think that our civilization is partly built upon intact sphincter muscles and our ability to control them!

II. The Pelvic Floor

The working of the pelvic floor muscles:

For a muscle to work efficiently and properly there are a few basic prerequisites. The first is that the muscle has to be properly implanted into a strong point from where it can exert traction or tension, or whatever its function may be. Think about a rope that is used to pull something. It obviously has to be attached securely at both ends to enable efficient transfer of the forces created. Secondly, the muscle needs to be innervated by nerves that would enable it to receive messages from the brain or spinal column. The return loop of the nerves is equally important since nerves have to return information to the spinal column or brain about the status of contraction and the position of the muscle. The brain has to know when to stop the contraction, or how to modify the contraction to exert just the right amount of force. It is amazing to realize the intricate control we have over our muscles under normal conditions. Thirdly, for a muscle to contract effectively, the muscle tissue has to be healthy and free of unnecessary scar formation or connective tissue (non-muscle tissue which keeps tissues together).

The sphincters we are concerned with here are under both conscious as well as involuntary control. This means that we can consciously and purposefully contract them, but that they also have the ability to contract as a reflex reaction without the need for us to consciously think about it.

The Pelvic Fascia:

Let us now look at the pelvic fascia.

Fascia as scaffolding:

In our imaginary picture the white sheet on top of the pelvic muscle trampoline represents the pelvic fascia. Fascial tissue is connective tissue, which basically is the soft tissue framework which holds our various body parts together, or apart, depending on their location. Without connective tissue we would literally fall apart in separate clumps of muscle, brain and various specialized tissues which would lack a recognizable form. Connective tissue is formed mainly by combinations of different types of collagen, especially type 3, but this is not important for an understanding of its function.

In the pelvis the fascial layers which surround the muscles of the pelvic floor not only provide a framework for the implantation of these muscles, but also surround the various pelvic organs and keep them each in a proper position. As an example, the recto-vaginal septum is a fascial layer, which separates the vagina from the rectum and prevents collapse of the front of the rectum wall into the vagina during straining, for instance when a bowel movement is passed. The pelvic fascia not only surrounds each tubular organ as it perforates the pelvic floor, but is integrally embedded in the wall of each organ. Tears or damage to this fascia can thus have significant consequences for both the normal functions of these organs, their position, as well as for the strength and integrity of their sidewalls.

The recto-vaginal fascia has been the subject of much controversy. Only very recently has it generally become accepted that there is such a thing in females. This is especially interesting since it has always been known to exist in the male. How about that for some rectal gender discrimination!?

This recto-vaginal septum (a septum is basically a fascia layer between two closely related organs) is currently thought to be important to establish the integrity of the vagina and rectal walls, and, to anchor the perineal body. The perineal body is the thickened part between the anal and vaginal openings. (It is that part which would be in direct contact with a bicycle seat.) The perineal body is basically formed by the insertion of multiple small muscles and strong connective tissue units, including the anchored recto-vaginal septum. Most of the muscles involved surround the lower vagina and can be clearly felt during a voluntary contraction when placing two fingers in the lower vagina. The external anal sphincter is also attached to the perineal body. Any disruption or dysfunction which results for instance from a tear through this area (which is extremely common during childbirth) could destroy the insertion point of multiple muscles, connective tissue structural units and the attachment of the recto-vaginal septum. This could have severe consequences for the integrity of the wall between the vagina and the rectum. Furthermore, as we now know, an intact insertion is one of the prerequisites for effective muscle action.

A tear in the recto-vaginal septum can cause the perineal body to lose its anchor and to fall downwards. This effect will be especially great during episodes of increased intraabdominal pressure (straining) thus causing the whole perineum to bulge downwards. This,, in turn, can cause branches of the pudendal nerves to stretch, which could potentially lead to further damage and set in motion a vicious circle which will worsen over time.

In the absence of adequate muscular support to the pelvic and abdominal contents, the full brunt of their weight and pressure falls on the fascial layer. In cases of muscular atrophy (weakening from loss of bulk), injury or weakness from other reasons, this fascial layer has the burdensome task of providing the only support. Unfortunately, some of the same causes of muscle deterioration cause tears or stretching of the fascia, so that even if initially intact, the absence of the pelvic floor muscle support, causes the fascial layer to stretch out over time or eventually to tear.

Fascia and genetics:

Certain inherited disorders of connective tissue cause a propensity to develop hernias and other tissue support problems. Unfortunately, there has been little research into the possible pelvic floor dysfunction of these patients, so we have little knowledge about the contribution of genetically abnormal connective tissue to the development of pelvic floor disorders and urogenital prolapse. Nevertheless, it is probably safe to state that there is a range of genetically determined connective tissue disorders, which might be highly prognostic (predictive) of possible future problems. It has also been suggested by numerous authors and researchers that there might be racially based differences in connective tissue strength, possibly related to differences in the collagen type mix in the connective tissues of the various races. It is known from experience (my own included) that pelvic prolapse is more common in certain races, but I have yet to see a large study confirming this or a definitive explanation for this phenomenon.

Fascia and hormones:

An interesting theory about acquired pelvic fascia weakness is that it is hormone dependent and, specifically, estrogen dependent. It is well known that many of the urogenital tissues are extremely sensitive to estrogens and rapidly become weaker in its absence, for instance in the postmenopausal phase. The theory states that a deficiency in estrogen would lead to a change in the composition of the connective tissue (collagen) types that form the pelvic fascia. Thus a strong collagen type would be displaced by a weaker type which is then unable to provide the support needed. Secondary prolapse and other problems might, as a result, develop with time. It follows, therefore, that hormone replacement therapy has a useful role to play in the prevention and possible improvement of such disorders. It is also believed that some of the muscles of the pelvic floor are also sensitive to estrogen and is negatively influenced by its absence or with lowered estrogen levels.

Estrogen deficiency, moreover, leads to decreased vascularization (blood flow) of the urethra and to decreased coaptation of the urethral walls. This basically means that the internal walls of the urethra will press less tightly together, and this can lead to urinary leakage. The atrophy and decreased vascularization lead to loss of thickness of the interior walls of the urethra, with the above-mentioned urinary leakage as the unfortunate result. Although estrogen deficiency is a common contributing factor, it would seldom be the sole cause for incontinence in the absence of pelvic floor weakness.

Another female hormone that is important to the health of fascia, is progesterone. This is the hormone that is secreted by the ovaries after ovulation to prepare the endometrial lining (lining of the uterus) for implantation by the embryo. This occurs every month in ovulating women during the latter half of the menstrual cycle, with a tremendous rise in progesterone levels when pregnancy ensues. The placenta eventually takes over the production of progesterone for the duration of the pregnancy, which in turn supports the placenta and causes changes in the mother's body to prepare her for the pregnancy as well as the delivery. The fetus (in this case in reality the placental half of the fetal-placental duet) has to do some work too!! If no pregnancy occurs, a drop in progesterone levels signals the onset of menstrual bleeding.

It is very well known that progesterone causes laxity of the body's ligaments, which is an important adaptation attempting to make the birth process easier. This laxity of one of the body's important connective tissue types (ligaments) might also be associated with weakness or laxity in others. Although not generally recognized as a direct cause for later problems, this might be one more important reason to refrain from activities such as heavy lifting during pregnancy and for about six weeks after birth.

Fascia, chronic straining, and smoking:

Unfortunately, the pelvic fascia is susceptible to tearing. This commonly happens during childbirth and we will discuss that in more detail later on. It is also susceptible to stretching, and unlike the muscles on our pelvic trampoline, it cannot bounce back to its normal shape. This is as a result of its particular collagen composition. Possible further causes of fascia damage include chronic straining during heavy lifting; chronic lung disease which causes chronic coughing (including smoking, which also decreases estrogen levels); or chronic constipation with repeated and constant straining in attempts to evacuate the bowel. As will be seen later, chronic straining from constipation can potentially lead to pelvic muscle damage too, but by another route.

Fascia and vitamins:

Another well-known cause for connective tissue weakness is vitamin deficiencies, especially vitamin C. It is conceivable that subclinical nutritional disorders could lead to degradation in the quality of the body's connective tissue and in that way contribute to genital prolapse and the other disorders of pelvic dysfunction. It is interesting to speculate whether nutritional disorders, for instance that found in many young women, might not through this route lead to later connective tissue (including pelvic floor) disorders.

II. The Pelvic Floor

Nerve Injuries:

As mentioned previously, muscles can only function if nerves innervate them. Damage to nerves can take many forms, and does not necessarily have to be permanent or complete. Nerves can be damaged by overstretching, by being crushed against a hard object (for instance a bony point), by tearing or by being cut (during an episiotomy, for instance). If the nerve is not completely severed, the term used is neuropraxia. Such injuries can usually repair themselves in time, although deficits often remain. More severe injuries can lead to the death of nerve fibers and subsequent dysfunction of the particular muscle innervated by that nerve fiber.

As we know, effective muscle action requires that the nerve supply be intact. Without this essential element, muscles degenerate and waste away (atrophy). The same is true for muscles which are not used for other reasons. Just think of someone whose leg is in a cast.

During vaginal childbirth there are multiple possibilities for nerve damage within the pelvic area. During descent of the fetus's head through the pelvis, the pelvic nerve plexuses and individual nerves are compressed against the bony pelvis. One of the very important nerves that supply the pelvic floor, namely the pudendal nerve, is very vulnerable to a combination of crushing and stretching forces. These nerves, one on each side, supply most of the voluntary muscles of the pelvic floor and perineum and are essential to normal pelvic muscle action. During their course through the pelvis, they angle sharply around bony points called the ischial spines. It is apt to think of the Latin root of the words "ischial spine" which can be translated as "thorn of the hip joint". The ischial spines (again one each side) are part of the ischial bones of which there are of course two. These are the lateral (side) bones of the pelvis. Since the inter-spinal distance is the narrowest part of the mid-pelvis, the fetal head invariably applies significant force to the pudendal nerves in these areas. Since the nerves are relatively unable to move because of their sharp angulation around these bony points, they are especially vulnerable to crushing, stretching and tearing forces.

Many investigators have proven, beyond reasonable doubt, that pelvic nerve injuries are extremely common during vaginal childbirth. It was found that the percentage of women who develop nerve injuries is as high as eighty percent.13This was found in women who gave birth vaginally or in women who had emergency cesarean sections after they had reached the second stage of labor. A cervix that is fully opened with the fetal head ready to come out defines the second stage of labor. During this stage the mother is usually actively pushing, the fetal head is deep in the pelvis, and the vagina as well as the pelvic muscles and fascial layers are maximally stretched. All the factors to cause compression and shearing forces on the pelvic nerves are thus in play.

Researchers have found no nerve damage after elective cesarean births. With elective cesarean births the fetal head is usually still high in the pelvis, or even above the pelvis, and at any rate the tremendous compression and stretching forces have not been applied.

The pudendal nerves are, in addition, the main nerves of the pelvic organ sphincter muscles (voluntary component). These, mainly, include the external anal sphincter, the bladder neck sphincter and certain small muscles surrounding the lower part of the vagina. Other nerves that might be damaged include the sympathetic and parasympathetic nerve chains, and this can lead to the dysfunction and weakening of the levator ani muscles (which help support the pelvic floor).

13. Tetzschner et al. Acta Obstet Gynecol Scan 1997; 76: 324

Operative vaginal deliveries and nerve damage:
It is now well accepted that operative vaginal delivery has the potential to increase the risk for pelvic damage. Forceps delivery, especially, has been shown to carry this risk. The vacuum extractor, is associated with a lower risk for this complication. The dilemma is that these operative procedures are, in some cases, essential to expedite delivery, or to make vaginal delivery possible at all. In those cases where labor has already reached the second stage (often after prolonged pushing), and vaginal operative procedures are considered, it is to a large degree probably already too late to do a cesarean section (in preference to operative vaginal delivery) to make a meaningful difference to the protection of the pelvic floor.

As mentioned, some of this damage heals with enough time. There are, however, disturbing studies which show that significant nerve damage persists in a large percentage of women after vaginal delivery. The pelvic fascia can usually overcome the resultant weakness in the levator ani muscles for a while only. This is of course only true if the fascia is intact and attached to begin with. With aging, natural processes and the increasing stretching of the fascia under the influence of the intraabdominal weight it now solely has to bear, the fascia eventually cannot support its burden effectively anymore and prolapse develops. As will be seen later, this can manifest as overt genital prolapse, or urinary or fecal incontinence. Weak sphincter muscles usually lead to incontinence problems. Sphincter defects can arise from the above-mentioned neurological damage or from more direct damage, which will be discussed next.

III. Pelvic Floor Disorders

1) Urinary incontinence:

Imagined not being able to control your urine. Imagine wetting yourself every time you cough, sneeze, run, jump, walk down stairs, play golf, tennis, or just horse around with your children or grandchildren… Sadly, this is exactly what millions of women experience daily. It is estimated that up to 10 million American women suffer from urinary incontinence. Walk around the shelves of your neighborhood pharmacy. It will become abundantly clear that incontinence means huge profits to manufacturers of protective pads and devices.
birthinjury1

Urinary incontinence is big business:

The economic impact of urinary incontinence in the United States alone was estimated at over 10 billion dollars per annum at 1987 prices, and this does not include indirect costs. As mentioned, the clearest indication of the prevalence of incontinence is the female sanitary market. It is a multi-billion dollar market and it is noticeable how often one encounters television advertisements for moisture protection which are targeted at women. Any way you look at it, incontinence is big business.


birthinjury2

III. Pelvic Floor Disorders

Effects on quality of life:

Urinary incontinence can be devastating to quality of life:

Urinary incontinence can be devastating physically, economically, and psychologically. It often leads to curtailment of enjoyable activities, social embarrassment, depression, and even isolation. The typical scenario is that any activity that would increase the pressure inside the abdominal cavity of women suffering from urinary incontinence could precipitate an uncontrolled squirt of urine. This typically occurs as a result of damage to
the pelvic floor, the bladder sphincters or the integrity of some finer control mechanisms, and is called genuine stress incontinence. These unfortunate women often tell me that whenever they leave their houses, they have to plan their trip or visit around the availability of washrooms. They are intimate with the exact location of every toilet in the immediate vicinity. By going to the toilet at every possible opportunity, they attempt to keep their bladders completely empty to avoid embarrassment and physical discomfort.

One of the common complaints I get from patients is that they cannot play with their children/grandchildren like before anymore for fear of embarrassing accidents. Since this problem, of course, also intrudes upon their professional lives, many women have an all-encompassing fear of public embarrassment. I have seen young women with major clinical depression as a result. It is therefore surprising and disconcerting that only an
estimated 25 to 50 percent of women with incontinence seek medical help.

Incontinence can also become a problem during the most intimate of all acts, namely, sexual intercourse. I once browsed through a book in a respected bookshop, which describes how to reach sexual ecstasy. One of the main points of this book was the phenomenon of female ejaculation. The author describes how a woman at the top of her excitement would and should ejaculate a large volume of clear fluid. Well – I'm sorry to disappoint, but…

Prevalence:

Urinary incontinence is pervasive:

It is estimated that up to 50 percent of women will experience symptomatic urinary incontinence! This figure is even higher in institutionalized elders. The figures vary widely from study to study. Even if given a conservative overall figure, the incidence of urinary incontinence is absolutely shocking. A stress urinary incontinence has been found to be the most prevalent, making up 77 percent of the incontinence in women in some studies. The figures vary according to the definitions used in the different studies as well as whether the studies used self-reporting or objective investigative results. Some women report incontinence but do not necessarily have significant problems with it since it might occasional, for instance, during a severe cold. The great tragedy, however, is the numbers of young woman that are inhibited from participating in ordinary activities that they enjoy or must do on a daily basis

III. Pelvic Floor Disorders

Types of urinary incontinence:

"stress vs. urgency":
An understanding of urinary incontinence is complicated by the fact that there are different types of incontinence, and that not all types of incontinence are related to pelvic floor damage. The most common type is stress urinary incontinence, also called genuine stress urinary incontinence and which usually is a consequence of pelvic floor damage or dysfunction. The typical case history is that a squirt of urine occurs in the event of increased intra-abdominal pressure (coughing, sneezing and the other triggers already mentioned). The great majority of women suffering from this have had vaginal childbirth, a fact that has been known since early times. In fact, in 1919, Howard A. Kelly, the first professor of gynecology at the Johns Hopkins Medical School, co-authored a text entitled " Disease of the Kidney, Ureters and Bladder". He wrote:"The commonest form of incontinence is the result of childbirth, entailing an injury to the neck of the bladder; it is occasionally seen in the elderly nullipara and is most common after the age of 40. It is usually progressive, beginning with an occasional dribble, later becoming more frequent and occurring on slight provocation. In its incipiency, a strain, cough, sneeze or stepping up to get on a tram car starts a little spurt of urine which, in the course of time, initiates the act which empties the Bladder".

Most studies have found a high incidence of urinary incontinence in pregnancy in healthy young women even during the first pregnancy. Prevalence rates as high as 50 percent have been reported. Most of these women recover urine control after the pregnancy, but not all. Unfortunately, a great many of those who recover control have sustained sufficient pelvic floor damage to destine them for future renewed urinary incontinence, with or without genital prolapse and anal incontinence.

One of the other relatively common causes of incontinence is so-called bladder instability. This would typically cause the feeling of urgency ("I have to gorightnow!") not necessarily associated with increased intra-abdominal pressure or urgency incontinence ("I have to go right now--oops--too late!"). Triggers for this kind of incontinence often include things such as hearing water running, feeling cold water on your hands, or seen a washroom.

Regrettably, it is usually impossible to determine which of the two causes predominate without further testing, since patients' histories alone are notoriously inaccurate. These two main causes of incontinence often occur together in the same patient, which makes it difficult to determine what therapeutic approach would be most effective or likely to succeed. Obvious pelvic floor prolapse, especially a prolapse of the bladder into the
vagina (so called cystocele), in the setting of a typical history, together with urine leakage during coughing make genuine stress incontinence the likely diagnosis. The price of being wrong however is so high that one would seldom resort to surgical intervention in the absence of corroborative information. This information can be obtained from a cystometrogram. This basically involves measuring the pressures inside the bladder during different activities, and during bladder filling with sterile water. Typically, urgency incontinence occurs after a rise in pressure inside the bladder related to a bladder muscle contraction. Somewhat simplistically, it is abnormal for the pressure inside the bladder to rise except when purposely voiding. Such abnormal pressure increases is the result of bladder instability, the causes of which will be shortly discussed later. More sophisticated cystometrogram instruments also measure contractions of the pelvic floor muscles and the bladder sphincters, as well as the pressure differentials between the bladder, the urethra, and the intra-abdominal cavity. The main purpose of a cystometrogram is to diagnose or exclude bladder instability, the presence of which has to be known to plan an intelligent therapeutic approach to the incontinence. The reason that it is important to rule out bladder instability is that surgery, in the setting of bladder instability, has a high risk of increasing the instability. Bladder instability (the medical term is "detrusor instability") means that the bladder muscle contracts when it is not supposed to. Under normal circumstances the bladder has the ability to distend enormously without any increase in pressure inside the bladder. This occurs as a result of passive distention without the occurrence of any detrusor contractions. As a result the normal person would still be comfortable with a bladder that is quite full, although he/she will be intermittently aware of it. The unstable detrusor, however, contracts with bladder filling or other external stimuli, for instance, to see or to hear running water, certain body movements and sometimes for no discernible reason that all. This then causes an intense feeling of the need to urinate even if there is only a little urine. This is sometimes the result of infection or interstitial cystitis (at a relatively common and extremely frustrating urological condition), and may also be caused by diabetes or other medical diseases. Very commonly, however, no obvious cause is found.

The presence of detrusor instability does not necessarily contraindicate surgery. Although this seems to contradict what I said before, I will try to explain. One of the worst mistakes a surgeon can make is to attempt surgical treatment on a patient who hasonlydetrusor instability. Surgery in this setting is very unlikely to be of any benefit to the patient and, ironically, can lead to a significant increase in the problem. With pure, or so-called genuine stress incontinence (in the absence of detrusor instability) surgery does have a definite role to play. Alternatives to surgery will be discussed a bit later.

More complicated are the cases where both types of incontinence occur together. It is well known that detrusor instability can sometimes be the result of pelvic floor damage and the resultant abnormal position of the bladder base. In such a case, surgery often cures not only the stress incontinence, but also the detrusor instability. It is a highly unpredictable outcome, nonetheless, and there is a risk that the instability will persist or increase postoperatively. Fortunately, postoperative instability is commonly transient and there are strong drugs available to suppress the abnormal detrusor contractions, which usually leads to significant improvement. It has to be noted however that this is a potential complication that might render a technically perfect operation a failure.

Unfortunately women are anatomically at much higher risk than men for the development of urinary incontinence. This is not only related to childbirth, but also in some degree, to the short urethra and it's anatomical relationship to the vagina. As a result of this, a significant number of perfectly young women suffer from the occasional urinary leak, but fortunately usually not to any serious degree.

III. Pelvic Floor Disorders

Urinary incontinence and the pelvic floor:

Clinically important, so-called genuine stress incontinence, on the other hand, usually occurs in the setting of pelvic floor defects. The normal control mechanisms of urinary continence are very complicated processes, which I will greatly simplify. An understanding of the main concepts is however necessary to understand why the intact pelvic floor is so important in this regard.

fascia

The urinary bladder is basically a reservoir. It is a sack lined with an impenetrable membrane, which is then surrounded by a strong muscle called the detrusor muscle. The outflow tube of this sack is called the urethra and it is approximately 4-5 cm in length. The junction between the urethra and the bladder is called the bladder neck area. A relatively sharp angle is formed between these two, which is important in continence control.

forces

A strong sphincter muscle (clamp) surrounds the bladder neck area and is under voluntary control. In contrast to this voluntary control the bladder muscle itself isnotunder voluntary control, but is carefully regulated by a special center in the spinal column called the micturition (urination) center. The brain does have some control over the micturition center, which gives one the ability to postpone urination until it is convenient. The normal position of the bladder is immediately on top of the vagina and lower part of the uterus, whereas the urethra lies on the lower part of the vaginal roof and is integrally associated with, and attached to, the top vaginal wall (its roof).

The pelvic fascia we have heard so much about surrounds the urethra and the vagina, and is suspended from the pelvic side walls (see illustrations). This creates suspension support for the urethra, the vaginal roof (also called the anterior or upper vaginal wall) as well as the bladder neck and the bladder itself. The integrity of the pelvic fascia, the anterior vaginal wall and the pelvic musculature is essential to maintain the normal position of the urethra, the bladder neck, and the bladder itself.

Continence is provided by a variety of finely balanced factors, which include the position of the bladder neck, the bladder neck sphincters, parts of the levator ani muscles, compression of the urethra and characteristics of the internal urethra itself. The bladder neck contains an involuntary internal (inside), and a voluntary external (outside), sphincter. These sphincter muscles, as do all other muscles, depend on the above-mentioned factors for their effective action. Damage to pelvic fascia or pelvic innervation seriously and negatively affect their action. These muscles are the same ones that one contracts to consciously stop the urine stream and do so by constricting the urethra. During this squeezing action, most of the pelvic voluntary muscles are at the same time contracted, including the levator ani muscles, the rectal sphincter and certain small muscles surrounding the opening of the vagina.

The position of the bladder neck is extremely important. To recap, there is an angle between the bladder and the urethra. When intraabdominal pressure is increased for instance during coughing, sneezing, etc., this tends to increase the angle, effectively kinking the urethra the way we would bend a garden hose to stop the flow. With an intact pelvic floor, especially the fascia, there will be little sagging in the anterior vaginal wall so that the increased pressure on the urethra (transmitted from the abdomen), will tend to effectively compress it against this unyielding floor, and thereby prevent leakage.

The internal structure of the urethra also helps to prevent urine leakage. The mucosal lining fits tightly together and prevents urine flow initiation. With aging, especially as estrogen levels fall, this lining fits together less tightly, which contributes to the problem. Less well understood is the function of the internal urethral muscles, but it is now well known that internal urethral deficiencies can lead to stress urinary incontinence.

Urinary incontinence and vaginal delivery:

It has been adequately demonstrated that vaginal delivery increases the bladder neck descent and decreases the ability of the pelvic muscles to elevate the urethra and the bladder base. During episodes of increased abdominal pressure, for instance during straining, the bladder neck is lower in women after vaginal delivery, compared to women who have not had children or women who have had elective cesarean sections. It was found that this positional change occurs in more than 50 percent of women after vaginal delivery and is usually persistent. In contrast, in patients who had elective cesarean births there is almost no difference. Damage to the pelvic floor with urethral detachment was already described in 1945, and it was estimated at that time to occur in a third of patients.

It is now known that the very first vaginal delivery can cause damage not only to the pelvic floor muscles and fascia, but also to the nerve innervation of the muscles, and in particular to branches of the pudendal nerve. Further deliveries are thought to add to this risk, although the contributory effect of subsequent deliveries is thought to be considerably smaller than the first. It is a well-known fact that subsequent births are usually easier than the first one. This makes sense not only if one considers the possibility of a "memory" effect in the effectiveness of the uterine muscles, but also the decreased difficulty in downward movement of the fetus. This, of course, is the result of decreased pelvic muscle tone, and generally relaxed vaginal tissues and fascia, resultant from the first birth.

The Odds Ratio (a statistical entity calculating the probability of something occurring, and used frequently in medicine) for vaginal childbirth as a risk for urinary incontinence has been calculated to be 11.15. This means that women are 11.15 times more likely to develop urinary incontinence after vaginal childbirth, compared to women who have not had vaginal births. This is an incredible statistic and equates to a thousand one hundred percent increased risk!

Other causes of urinary incontinence:

Some other types of urinary incontinence include overflow incontinence, true incontinence, functional incontinence and other usually temporary and reversible types of urinary incontinence.

Overflow incontinence is defined as the involuntary loss of urine associated with over-distention of the bladder. In most cases this is a result of outflow tract (urethral) obstruction or detrusor under activity. Therefore, both an overactive bladder muscle and an underactive one can lead to urinary incontinence. Fortunately, outflow tract obstruction is relatively uncommon in women, but it is sometimes caused by surgery for genuine stress incontinence. Causes of detrusor under activity (also called detrusor atony), include such medical conditions as diabetes, thyroid disease, diseases of the bladder nerves, certain medications, alcohol, infections and interstitial cystitis (a chronic potentially debilitating urological condition).

True urinary incontinence is the result of a hole between a urine containing organ and the outside. Usually this means a hole in the bladder with a tract into the vagina (remember the vagina and bladder is only separated by a few layers), but could also involve the ureter or urethra. With modern obstetric management in Western countries this is fortunately rare, but in older times obstructive labor commonly led to such fistulas (holes) leading to permanent urinary leakage.

Functional incontinence occurs when a person with a normal urinary tract is unable, or unwilling, to reach the toilet to urinate.

Other transient causes include such things as delirium, atrophic vaginitis (thin vaginal skin as a result of a lack of estrogen), medication, psychiatric disorders, etc.

The most common scenario presented to clinical practitioners, however, is the problem of stress urinary incontinence in the setting of obvious pelvic floor defects. Quite often the urinary incontinence problem is one of a number of pelvic floor support problems which need to be addressed concurrently to provide the best long-term solution.

III. Pelvic Floor Disorders

Four non-surgical treatment options for urinary incontinence:

"Every solution breeds new problems 15."

An accurate diagnosis is paramount, since all treatment decisions depend on this most important function of the clinician. As there is often a confusing mix of different problems and causes, special tests are often required to make the correct diagnosis. Many of these problems will not be discussed, as they fall outside the scope of this book. We are mostly concerned with pelvic floor damage, so I will discuss only some treatment and prevention strategies for genuine stress urinary incontinence.

Obesity and smoking:

Stress incontinence is associated with pressure differences between the bladder and the urethra and it follows therefore, that anything, which increases this pressure difference, will tend to increase the problem. It is logical to assume that obesity, with the concomitant extra weight on the bladder, will only make the problem worse. Some patients can achieve dramatic improvement in their problem simply by losing weight. I say this knowing full well that many people find it impossible to shed those unwanted kilograms. Severe stress incontinence greatly curtails physical activity, which of course makes the whole endeavor so much more difficult.

Another lifestyle issue that has to be dealt with at the outset is the smoking habit. Smoking lowers estrogen levels in the body, and it also leads to chronic coughing. There you have it – another good reason to "butt out…

Medication:

Medication plays a small role in the treatment of genuine stress incontinence. Since the problem is anatomical in most cases, medication does not lead to much improvement. In cases of bladder instability, camouflaged as stress incontinence, (yes that happens), medical therapy is the right choice. This situation can occur if the primary trigger for an abnormal bladder contraction is not the usual visual or auditory stimulus, but something like a cough. The leakage is thus a result of the bladder contraction and not from abnormal pressure distribution as in genuine stress incontinence. If the contraction occurs soon enough after the trigger, it might be impossible to distinguish between the two causes just by history alone. The importance of an accurate diagnosis is, once again, all-important.

One medication that might have a role in the treatment of genuine stress urinary incontinence, however, is estrogen. As mentioned before, estrogen is necessary for normal urethral coaptation (high pressure in the urethra itself, resulting from the walls pressing together). A lack of estrogen can sometimes be helpful in the treatment of stress incontinence, but is obviously more applicable in the postmenopausal, older patient.

Pelvic floor exercises:

As a general rule, the simplest solution likely to succeed should be tried first. One of the first options include ways to strengthen the pelvic floor muscles. Most women are vaguely aware of the pelvic floor muscle exercises called "Kegel's" exercises. Basically, these exercises involve the repetitive contraction of the levator ani and sphincter muscles to the point of exhaustion. One might see this as " bodybuilding" of the pelvis. Just as bodybuilding is extremely hard work and has to be done diligently and for a long period of time to see any effects, pelvic floor exercises do not provide a quick fix. The television advertisers who promise a miraculously toned body with minimal effort are unfortunately lying to you.

"No matter how often a lie is shown to be false, there will remain a percentage of people who will believe it true 16."

It has been my experience that few women obtain good results from exercises alone. Just as most new gym members exercise enthusiastically for three weeks to one month, after which their workouts become progressively more infrequent until they finally stop, so most women stop doing the pelvic exercises, or they do not do them frequently or intensely enough to be of much benefit.

Having said this however, for the highly motivated individual woman, especially those without severe pelvic fascia or nerve injuries, diligently performed pelvic floor exercises could make a big difference and sometimes even to cure. Exercise will increase muscle strength, but unfortunately it has no effect on damaged nerves or fascia, especially tears or disruption. In the presence of significant denervation of the pelvic floor muscles, or obvious fascial detachment, one should have guarded optimism. However, since it is completely safe and has no negative side effects, everybody should try these exercises as a primary treatment option or an adjunct to other modalities. To keep motivation high and to be sure that the exercises are done correctly, biofeedback or other professional help is preferable. Unfortunately this is logistically or financially out of reach for most women.

Following is a very simple and easy to understand "Kegel" exercise program. I found this description of pelvic floor exercises one night while browsing the net. I thought it was an excellent, beautifully descriptive explanation, and would like to share it with a wider audience. Unfortunately I have no idea who the original author was, so cannot give due credit.

KEGEL EXERCISES

For many years, patients have been advised that the proper way to perform Kegel exercises was to activate those pelvic floor muscles that would allow the patient to stop and then start the urinary stream. A better way of describing the proper way to perform Kegel exercises is:

  1. Imagine that rather abruptly you are experiencing a strong need to either pass gas or have a bowel movement; however the rest room is occupied and you will have to wait a few minutes. What do you do to avoid an accidental stool loss??? As you tighten the muscles in your pelvic diaphragm that will prevent that loss of gas/stool, and hold it, imagine that NOW you perceive a strong desire to void urine …
  2. But the restroom is STILL occupied!! You now have to hold tight both these muscle groups (stool and urine). Do this for 10 seconds, then relax for 10 seconds. Repeat 10 times in a row, (rectal then vaginal). This is called a set. Perform three sets a day for at least six weeks.

Properly and diligently performed, there are some studies indicating significant reduction in the need for surgery for stress incontinence after six weeks. The beauty of Kegel exercises is that there is no need for special equipment, there are no training fees, and you can do them anywhere! Sometimes, patients may not know how to activate these unused muscles so during a pelvic exam, your doctor can help focus you on the muscles needed during that examination by asking you to tighten here (rectally) and then here (vaginally). By identifying the muscle groups in this way, the
proper neuromuscular connections can be made very quickly. Kegel exercises are worthwhile if done correctly and consistently.

Vaginal cones:

Vaginal cones are basically cone shaped weights that are used, in effect, to do "vaginal weight training". Progressively heavier weights are placed in the vagina and the patient tries to keep them in for as long as possible by tightening the vaginal and, by implication, the pelvic floor muscles. Overall, this method is not popular and does not offer significant benefits over exercises without the weights, provided the latter are done properly.

Electrical muscle stimulation:
Many people are familiar with the electrical muscle stimulation process used by physiotherapists to stimulate various muscles. This modality is ordinarily used for rehabilitation after injuries as an adjunct to the overall therapy plan. Similar equipment can be utilized to stimulate the levator ani muscles. It is not a popular method (for obvious reasons) although, like almost everything, it has its enthusiasts.

Pessary:

The next possible option is the use of a pessary. This involves the wearing of a device in the vagina that effectively supports and pushes the bladder neck area upwards. Although it works effectively for some, I have found the acceptability level to be low over the long term, especially in younger women. This is not surprising. Pessaries are sometimes uncomfortable, need to be cleaned periodically, and usually need to be removed prior to intercourse. Finally, they do not cure the problem but merely mask the symptoms, which is unacceptable for most patients. As a result, they are used almost exclusively in the old or frail, or for temporary relief while awaiting surgery. They furthermore have a much bigger role in patients with prolapse as their main problem, rather than incontinence.

Since there is a multitude of different types of pessaries available, it is quite an art to find the one that will work best for an individual woman.

This brings us to surgery.

15.The Complete Murphy's Law by Arthur Bloch. Published by Price Stern Sloan. Page 5

16. "Law of the lie" The Complete Murphy's Law by Arthur Bloch. Published by Price Stern Sloan. Page 8

III. Pelvic Floor Disorders

Surgery for treating urinary incontinence:

"The advance of science can be measured by the rate at which exceptions to previously held laws accumulate.
Corollaries:

1. Exceptions always outnumber rules.
2. There are always exceptions to established exceptions.
3. By the time one masters the exceptions, no one recalls the rules to which they apply 17."

There is no ideal surgical solution:

It is a well-known surgical principal principle that the more surgical procedures there are for the same problem, the more likely it is that none of the procedures are ideal. The reasons for this are obvious. If there were one perfect surgical solution, everybody would be doing the same thing. Urinary incontinence and, specifically, stress urinary incontinence, is one of those areas where there are an incredible number of different surgical procedures performed. The gynecological and urological literature is full of contradictory and speculative opinions, which makes the evaluation and comparison of the different surgical procedures very difficult. One of the main problems, in terms of comparing different studies, is the fact that there are no uniform outcome measurements used by researchers. I want to remind the reader of the "whole picture principle" quoted
earlier:

"Research scientists are so wrapped up in their own narrow endeavors that they cannot possibly see the whole picture of anything, including their own research 18."

The problem is that different definitions are used, not only for the initial problem but also for the outcome results. Some studies use subjective measurements (surveys filled in by patients) to determine surgical results, whereas others use objective (urodynamic testing, like the cystometrogram) studies. Follow-up periods after the surgery vary widely too, and some of the newer surgical procedures, for example, laparoscopic procedures, and newer sling procedures, have relatively short follow-up periods. This causes uncertainly about the long-term results of these procedures. The fragmentation of research is compounded by a certain amount of rivalry between urological and gynecological colleagues, which leads each specialty to carry out research in isolation from the other, with little sharing of information.

As mentioned earlier, detrusor instability is a relatively common complication or side effect of the surgery for genuine stress incontinence, but, in the setting of mixed incontinence, the instability often improves after the anatomical defects have been corrected. In cases where pure detrusor instability causes the incontinence, any surgery is highly inappropriate as the primary treatment option. Herein lie not only the science, but also the art, which makes this particular field of medicine so interesting.

Expected cure rates:

Objective cure rates for various surgical procedures vary widely, with a success rate of approximately 40 percent to 90 percent. Realistically, the most that could be expected, with the best procedures that is, would be cure rates of approximately 70-80 percent after about five years. There is a definite element of time decay (more recurrent problems as time goes on), which tends to be significantly more pronounced in patients with medical conditions such as obesity, chronic cough from smoking and asthma. The genetically determined strength of the body's connective tissue, as discussed in a previous section, is an important factor not only for the immediate operative result, but for the likelihood of a relapse.

Surgical principles:

Almost all surgical procedures have one element in common. They all attempt to elevate the bladder neck and the first part of the urethra, and to reconstitute the support underneath these two structures.

Vaginal surgery:

The original surgery performed for this problem was the anterior vaginal repair. This procedure is done entirely via the vagina and is still performed routinely for the repair of a cystocele (see later). Basically, the cystocele is repaired, and one or more extra sutures are placed in the fascia underneath the bladder neck to pull the bladder neck up. Deep bites are taken into this fascia which are then pulled together. The problem is that the sutures are not fixed to any strong anchor points but only to the fascia itself. Since failure of this same fascia probably contributed to the original problem, it is no surprise that this surgical procedure is the least effective over the long-term. When the fascia has pulled away from the pelvic side-walls, which is a common cause of the problem in the first place, it is almost ridiculous to imagine that bundling it up in the midline will create long-term support, and so cystoceles (and concomitant stress incontinence) often recur if treated this way, in spite of skilled surgery.

Abdominal procedures:

More appropriate surgery for genuine stress incontinence anchors the pelvic fascia to a strong point that is higher than the urethra, which effectively suspends the urethral support as well as lifts it up to a more normal position. Surgeries that fall into this category include the so-called Marshall-Marchetti-Krantz procedure, the Burch procedure, certain sling procedures as well as the various needle suspension operations. I will not discuss these operations in detail but will point out a few important factors as I see them.

The Marshall-Marchetti-Krantz procedure (usually only called the Marshall-Marchetti) was the original procedure described in 1949 by Marshall, Marchetti and Krantz (who else?), and uses the pelvic bone periostium (bone lining) as its strong anchor point. The Burch procedure, (guess who described it in 1962?) uses a ligament on top of the pelvic bone as its anchor point. The Burch procedure has become the more accepted procedure, because of certain theoretical advantages over the Marshall-Marchetti procedure. These include less risk of obstruction of the urethra, and the absence of the risk of osteitis (inflammation or infection) of the pubic bone. Both these operations are usually done as abdominal procedures and so carry many of the implications of abdominal surgery.

Another surgical procedure that has gained quite a following over the last few years is the so-called para-vaginal repair. This surgery makes a lot of intuitive sense, since its whole premise is the repair of the causal abnormality by re-attachment of the pelvic fascia to the pelvic side wall. This part of the pelvic fascia is called the pubocervical fascia, and although the name is not important,thisis the most important part of the vaginal fascia involved in the support of the anterior vaginal wall and therefore is also closely related to the urethra. The premise of the para-vaginal repair is that many cases of genuine stress urinary incontinence, especially in the setting of a cystocele, happen when the pubocervical fascia tears away from the lateral pelvic side walls where it is attached to the so-called white line of the pelvis (the medical term is the arcus tendineus fascia pelvis). If you think back to our pelvic trampoline model, this attachment of the fascia to the pelvic side walls corresponds to the rolled up edges of the white sheet that was attached, not to the frame itself, but to the underlying canvas that represents the levator ani muscle group. This thickening of fascia forms the so-called white line (arcus tendineus).

A rupture leading to prolapse, and possibly incontinence, can occur on the left or the right side, but has been found to be more common on the right. Re-attachment of this fascia can be accomplished during a Burch or a Marshall-Marchetti procedure by adding certain steps to the procedure. Unfortunately, too many surgeons (urologists and gynecologists alike) totally ignore this underlying cause for many cases of cystocele and urinary incontinence. I believe this results from their incomplete understanding of the pelvic fascia and its disorders. They fail to seek what the underlying problem is, and therefore what logically should be done to correct it. They resort instead to a "one-shoe-fits-all" approach, and do the same surgery on everybody. In my opinion this is a dubious approach.

Para-vaginal repair has also been described as a vaginal procedure, but unfortunately this is far more difficult and certainly not part of the average gynecologists' armamentarium.

Laparoscopic surgery:

More recently, laparoscopic techniques have developed, and they enable surgeons to perform these procedures laparoscopically (minimal access surgery or "keyhole" surgery). Although it seems as if the end results are comparable to open surgery, their success is still controversial, partly because the long term results are still outstanding. The immediate postoperative recovery is certainly easier and quicker, but patients still have to take the same precautions for the first six weeks to three months. These include a ban on anything that would put a strain on the sutures like lifting, straining, repetitive bending, sexual activity, etc. Before the healing process has had a chance to form strong attachments to keep the bladder and urethra in position, the newly suspended fascia only hangs from a few sutures, which could easily come undone. The real recovery period is thus in my view often somewhat simplistically minimized.

Another problem is the significantly increased operating time it takes to perform these procedures laparoscopically. This factor has led many (if not most) gynecologists who started off enthusiastically on the laparoscopic bandwagon, to abandon it after a while. This especially becomes a problem in countries like Canada where operating room time is in very short supply, and where surgeons get paid a flat (government set) fee for a
procedure, whichever way it is performed. Most surgeons have realized that with the time it takes, and with their available operating room time, they cannot afford to do it.

Needle procedures:

Needle suspension operations are mostly done from the vaginal side, with only one or two small abdominal incisions (approximately 1.5 to 2 cm each). The endopelvic fascia on each side of the bladder neck is sutured, and the sutures are pulled past the bladder, behind the pubic bone, and through the abdominal wall using a long needle (hence the name). They are then tied in such a way that they are suspended from the rectus sheath.

Although very effective in the right patient, the drawback is that the anchor point used is the rectus sheath, and it is not very strong in some patients. The rectus sheath is a relatively thick fascia layer covering the two big abdominal muscles called the rectus muscles. Since this fascia is understandably weaker than ligament or bone, the sutures may cut through or tear out. As a result, these operations are usually performed in the less active and older patients who might be anesthetic risks for larger abdominal procedures. There are numerous examples of different modifications of this operation.

Slings:

Sling procedures incorporate a sling of suspension material underneath the bladder neck and urethra, which is then sutured to different anchor points. Other than the suspension or elevation effect, the sling also creates more direct compression of the urethra. These procedures are usually done in patients with dysfunction of the internal urethral continence components, which is especially common in patients with a history of previous anti-incontinence surgery. Unfortunately, they also have a higher postoperative complication rate, including injuries to the bladder and urethra, as well as obstruction and difficulty urinating.

A new and in my view extremely exciting new procedure has been introduced to North America in 1999. This is the so-called TVT or "Tension free Vaginal Tape" procedure. The procedure was developed in Upsala, Sweden, and was clinically tested and introduced in Europe a few years before coming to North America. It evolved from a revolutionary new view of incontinence and urethral support, placing more emphasis on distal (closer to the exit) urethral fascia support and discounting the elevation aspects of all other incontinence procedures.

It is performed as an outpatient procedure, takes about 20-25 minutes to do, and involves only a small incision in the vagina under the urethra, and similar abdominal incisions as for the standard needle procedures. Other that with most other anti-incontinence procedures where patients might have considerable difficulty with urination after the operation, most (about 90%) of TVT patients will void within the first 24 hours. For this
reason, the TVT operation is the only anti-incontinence operation where a catheter is not usually required. A further neat aspect of the procedure is the fact that it can be done under a very light spinal anesthetic or under local anesthetic only. In fact, it is important that the patient be awake and is able to cooperate, since part of the procedure is a dynamic test of leakage, to measure just how tight the TVT tape should be placed. The idea is to create support for the urethra with a synthetic tape, to replace the lost support of the damaged fascia. The tape is placed "tension free", but just tight enough to objectively stop the incontinence. It is placed past the bladder with special needles that then exit the abdominal wall through the small incisions. Here the procedure also differs radically from the needle procedures. Whereas the sutures of the needle procedures are sutured across the rectus sheath for their support, with the possible problems of cutting through, the tape of the TVT is left without any need for suturing. Suffice to say that the tape has been designed in such a way that suturing is unnecessary. Although it sounds incredulous at first, the design concept is really brilliant, and best of all, it seems to work.

Although the TVT procedure has gained international acceptance and the preliminary reports indicate excellent cure rates, it needs to be remembered that it is still a new procedure, with no long term follow-up data available. There have also been reports of a few significant complications. This can unfortunately be said for all anti-incontinence operations, however.

Paraurethral injections:

Some patients with dysfunction of the internal urethral mechanisms are candidates for the direct injection of material into the paraurethral (immediately adjacent) tissue, to deliberately cause a partial obstruction. Various materials are used for this, including some materials foreign to the body, but some natural materials like collagen are also used. Although quite simple and relatively easy, these procedures may usually have to be repeated a number of times, especially with collagen injections. Total obstruction and difficulty with voiding are possible problems, although these are potential problems withanyof the surgical methods. Unfortunately this is an expensive method and it is not freely available. It is usually performed in patients where previous surgeries have failed, and who have urethras that have little or no function beyond being a fixed and dilated
tube.

Complications of surgery:

As alluded to before, surgery for incontinence may cause new problems. The elevation of the bladder neck, the inflammation of the healing process and the presence of foreign suture material may all contribute to the development of an unstable bladder, even to the point of causing urgency incontinence. Although usually temporary it may sometimes be a long-term problem that necessitates medical management. Fortunately, there is excellent medication available to us, which treats this effectively in most patients. Injuries to the bladder, the two ureters or the urethra are possible, although not common, and can occur in even the most experienced hands. Some of these injuries might necessitate further surgery to correct. Urinary obstruction postoperatively is extremely common, but is also fortunately usually only temporary. Prolonged urinary drainage by catheter or intermittent catheterization is sometimes necessary. One further possible complication that has to be mentioned is the increased incidence of enterocele formation after bladder suspension operations. This usually occurs some time later but there is no doubt about the increased long-term risk for this problem. Enteroceles will be discussed further on. I surely do not have to say much about the possibility of bleeding, infective and anesthetic complications. These are possible complications of all major surgeries.

Fortunately, all is not doom and gloom. Most patients will have an excellent surgical result, with either complete cure or a significant improvement in their urinary incontinence. Many patients start living again to their full potential after successful anti-incontinence surgery, and these women are usually some of the most grateful patients.

17. "First Law of Scientific Progress" The Complete Murphy's Law by Arthur Bloch. Published by Price Stern Sloan. Page 130

18. "Whole picture principle" The Complete Murphy's Law by Arthur Bloch. Published by Price Stern Sloan. Page 126

III. Pelvic Floor Disorders

2) Anal incontinence:

Understanding anal incontinence and anal continence control:

I will not attempt to illustrate the indignities of anal incontinence with examples. It should be obvious that any significant incontinence of stool or gas will have a severely negative influence on quality of life.

To understand some of the causes of anal incontinence, which arise out of vaginal childbirth, we need to look at the anatomy again. Very few people actually stop to think about the processes involved in our ability to control our excretory organ systems. Bowel control is extremely fascinating, especially since the continence mechanisms have to distinguish between different states of matter. The contents of the sigmoid colon (the lower part of the large bowel) include not only solid fecal matter, but also water and various amounts of gas. Normally we are able to distinguish the difference. The ability to pass gas without simultaneously passing fluid stool illustrates the amazingly intricate control we have.

As with urinary control, there are involuntary and voluntary mechanisms, which include the sphincter muscles, as well as parts of the levator ani muscle. Similar to the bladder neck, the sphincters consist of an external (outside) as well as an internal (inside) sphincter, with only the external sphincter under full voluntary control. Again, reflexes play a major role in the constriction of these sphincters and muscles during sudden episodes of increased intraabdominal pressure. Remember our pelvic floor trampoline model? The muscle loop represented by the seat belt material that looped around the holes in the trampoline represents a part of the levator ani muscle called the puborectalis muscle (see illustration). The name implies that the muscle has something to do with the pubis as well as the rectum, and that is exactly the case. This part of the levator ani muscle originates from the pubic bone, loops around the rectum and implants in the pubis again. The pubic bone is the bone palpable underneath the mons pubis (area underneath the sexual hair), above and behind the clitoris. When it contracts, it pulls the rectum forwards and kinks it, which is one of the most important parts of fecal continence control. An intact and strong levator ani muscle with normal innervation is essential for this mechanism to work effectively.

Anal sphincter injuries:

Another essential part of anal continence control is the external anal sphincter. Injury to this sphincter is regrettably one of the most common injuries sustained during vaginal childbirth. In fact, using sophisticated internal ultrasound techniques, injuries to the anal sphincters have been demonstrated in up to 44 percent of women after delivering their first baby. The incidence of fecal urgency or anal incontinence has been found to be as high as 20 percent, and although most patients recover, these problems persist for a significant number, and up to two percent of women remain completely incontinent for flatus (gas) or feces. The strength of voluntary anal sphincter contraction was found to be persistently low after vaginal delivery, both immediately postpartum and two months later. Those unfortunate women who develop rupture of their anal sphincters during birth have an increased chance for persistent symptoms of anal dysfunction and incontinence which has been estimated at up to 50 percent even with adequate repair. Studies differ widely in their findings, and at least one recent Canadian study showed more promising outcomes. This study has not been peer reviewed at the time of this writing however and the overwhelming evidence thus still points at significant risk of prolonged problems.

Episiotomy and tearing:

Episiotomy:

Until recently episiotomies were done in an attempt to prevent vaginal tears and, especially, anal sphincter tears. Episiotomies have since fallen into disfavor since it was discovered that they do not successfully prevent bad tears. Although this has been adequately confirmed in large studies, most obstetricians will agree that episiotomy still has a place in modern obstetrics. Episiotomy can certainly shorten the second stage in some patients and can also potentially prevent some of the nerve injuring distension of the perineum right at the end of labor. It is equally true however, that episiotomy per se leads to the transection of some nerve fibers.

No one that has observed childbirth can help but be impressed by the incredible stretching that the vagina and perineum undergo. It is this stretching that is considered so damaging to the pudendal nerve and which can also lead to tears of the pelvic fascia. During birth, the vagina and perineum not only stretch by dilating, but as a result of the downward forces, the perineum also bulges downward. Earlier on I discussed the recto-vaginal septum, which anchors the perineum and prevents it from collapsing downward under the influence of gravity and intraabdominal pressure. The forceful stretching during childbirth sometimes tears this important part of the pelvic fascia, causing a loss of perineal support. This, in turn, leads to excessive perineal bulging and secondary pudendal nerve injury.

The external anal sphincter is innervated by the pudendal nerves, which, as we already know, are at risk during delivery. Partial denervation of the pelvic floor has been shown in up to 80 percent of women after delivering their first baby, and this usually involves the pudendal nerve.

Tearing:

Perineal tears during vaginal birth are so common as to be more the rule than the exception. This is especially true in primigravidas (first time moms) and it is usually impossible to predict in whom perineal tears will occur. Fortunately the tears usually involve only the mucosal lining (moist skin layer ) of the vagina and is then classified as a grade one tear. If the tear involves the underlying muscle of the vagina, or even the pelvic floor muscle, it is classified as grade two, whereas a tear of the external anal sphincter is a grade three tear. If the tear is even more extensive and has torn right through the vagina into the bowel, including a total disruption of the external anal sphincter, it is a grade four tear. As already mentioned, a very high percentage of women sustain injuries to their anal sphincters that can be demonstrated by ultrasound or other sophisticated techniques. Most of these are however not clinically appreciated.

It is the responsibility of the caregiver to suture these tears in an anatomically correct way to reconstitutes the different layers. As a result of the significant swelling, bruising and distortion of the tissue planes as well as the concomitant bleeding immediately after childbirth, it is sometimes quite difficult to do just that. Improperly or hastily repaired tears or episiotomies can lead to long-term disability, which includes incontinence or pain during intercourse. As with most surgeries, the first repair is the most important. All subsequent attempts will have to contend with scarred, denervated and devascularized tissue (tissue that has lost its normal nerve and blood supply). The latest information on the suturing of episiotomies indicates that there might be some advantage to leaving the outside skin layer open, rather than suturing it. Although this flies in the face of conventional wisdom, it seems this might lead to fewer wound breakdowns, possibly related to a decreased incidence of haematoma formation (bloodclot entrapment).

Other factors related to damage:

A few factors have been shown to increase the risk of injury to the pelvic floor and the anal sphincter muscles. These include multiparity (many babies), big babies, instrumental delivery (forceps or obstetrical vacuum), prolonged second stage labor, an abnormal position of the baby during delivery and a history of a previous injury incurred during childbirth. It has been found that forceps delivery is significantly associated with an increased risk of pelvic floor injury. Vacuum extraction seems to be significantly safer in this regard. Unfortunately, instrumental vaginal deliveries cannot be totally eliminated. By allowing a much longer second stage of labor the incidence of instrumental deliveries can and has been decreased, but it is now well-known that a prolonged second stage is another significant risk factor. This knowledge is usually totally disregarded by the " natural childbirth" movement, but it is likely that many of its supporters are simply unaware of the facts. Most of the consequences of a damaged pelvic floor usually show up years after childbirth, and it is difficult to get excited or overly concerned about a remote possibility in the face of one of the most emotional, exciting and significant moments of a person's life.

Surgery for anal incontinence:

Surgery for anal incontinence generally involves repair of the perineum and the external anal sphincter. The surgery is often done immediately postpartum if a sphincter or perineal laceration is identified. Incontinence however usually implies previous injury and the surgery is thus done electively (at a predetermined date) at a later stage.

III. Pelvic Floor Disorders

3) Genital prolapse:

Genital prolapse:

  • Uterine prolapse
  • Cystocele
  • Rectocele
  • Enterocele
  • Rectal prolapse

Genital prolapse can involve any of the main pelvic organs including the bladder, uterus and cervix, and the bowel. Women suffering from genital prolapse often have associated urinary or anal incontinence, although it is urinary incontinence which is most common. Symptoms are dependent on the specific abnormality, but usually include a feeling of pelvic fullness or discomfort, lower back discomfort or the appearance of a bulge in, oreven out of, the vagina.

Uterine prolapse:

With gross uterine prolapse, the uterus sometimes protrudes completely out of the body. Not only does this cause significant discomfort especially when erect, but also such women usually have to push it back in before they can sit down. Even in lesser degrees of uterine prolapse the feeling of vaginal fullness can be extreme. The lower part of the uterus and cervix often becomes swollen and this, together with continual scratching on clothes, pads and pantiliners, can cause an ulcer to develop, which can bleed or cause a discharge. Although this severe degree of prolapse (called total procidentia) is by no means rare, the more usual degree of uterine prolapse is far more moderate. It would involve the uterus and cervix moving up and down in the vagina (almost like a piston in a sleeve).

Uterine prolapse is the result of damage to the support structures at multiple levels. By now you are familiar with the levator ani muscles and the pelvic fascia as support structures. Uterine support, in addition, involves certain specific ligaments and is dependent on a normal uterine position in the pelvis.

The uterus is usually tilted and bent forwards in such a way that in the erect (standing) position its long axis is lying almost horizontal (level with the ground) and directed forward. In this horizontal position, the shelf of the levator ani muscles and the pelvic fascia support the bulk of its mass. In some women it is bent backwards and, although this is less common, almost the same applies. The uterosacral and cardinal ligaments are specific ligaments attached to the lower part of the uterus and to the pelvic side walls (see illustrations). These ligaments are usually very strong and provide significant support to the uterus.

Damage to the pelvic floor leads to an increased aperture of the opening that the vagina and cervix penetrate, which as we know is the result of weak, wasted or torn levator ani muscles and pelvic fascia. In the setting of stretched or weak uterosacral and cardinal ligaments, it is not surprising that the uterus would simply slide down through this opening. It is really a simple matter of gravity - if the anchors of the uterus fail and the underlying support is weak, the uterus will descend.

As mentioned before, all the pelvic support structures are less rigid and more pliable in pregnancy, which explains to some degree the occurrence of uterine prolapse in the occasional women even during their first pregnancy. Of course, the added weight of the fetus and increased uterine weight are significant co-factors in the development of this problem, but fortunately as the uterus enlarges it reaches a point where it is too large to
move through the pelvis. This solves the problem for the moment, although such women are at higher risk for a reoccurrence during future pregnancies and I would consider them to be at high risk for future genital prolapse after pregnancy.

Cystocele:A cystocele is an abnormal bulging of the bladder into the vaginal roof (anterior vaginal wall). This is experienced as a bulge in the vagina from the top, which sometimes comes right down to the vaginal entrance and even through the entrance. The anatomical defects are by now familiar. These, not surprisingly, involve torn or fractured pelvic fascial layers, ruptured fascial ligaments, or levator ani muscles weakened by one of the factors discussed earlier.

Cystoceles are commonly associated with urinary incontinence as a result of bladder neck support deficiency, associated with the injuries that cause the cystocele in the first place and other factors already outlined. Urinary incontinence does not always occur in the setting of a cystocele, so it is sometimes difficult to understand why some patients are totally dry in the presence of an obvious cystocele.

Some very large cystoceles cure the incontinence problem by kinking the urethra by virtue of their extreme prolapse. This could in the long run lead to renal (kidney) problems resulting from recurrent infections, or increased backpressure on the kidneys. Curing these cystoceles sometimes has the unfortunate side effect of unmasking the stress incontinence, so while the patient is cured of her cystocele she is not much better off. It is thus important that this be taken into consideration when surgery is planned for a cystocele.

III. Pelvic Floor Disorders

3) Genital prolapse:

Rectocele:

Rupture of the recto-vaginal septum, could lead to bulging of the rectal wall into the vagina. This is called a rectocele, and often occurs in the setting of weakened levator ani muscles and an increased urogenital aperture (the opening in the pelvic floor perforated by the urethra, vagina and rectum). The bulge might be low down in the vagina or involve the whole length of the posterior vagina, depending on where and how extensive the damage and the tears in the fascial layer are. This rectal bulge can almost be visualized as a ballooning of the bowel into the vagina with the resultant effect of fecal material collecting in this pouch. Patients often complain of constipation, and a need to reduce the vaginal bulge by putting their fingers in their vaginas to assist defecation. In lesser degrees this fecal collection might cause a feeling of pelvic fullness or incomplete bowel evacuation. Just as cystoceles are often associated with urinary incontinence, rectoceles are often associated with various bowel function abnormalities, including constipation and fecal or gas incontinence. Rectoceles often occur in the setting of associated perineal body injury, often with injury to the external anal sphincter. Having read this far, it is obvious that in those cases, anal incontinence is especially likely.

rectocele

Enterocele:

The intraabdominal space between the lower part of the uterus, vagina and the rectum is called the "pouch of Douglas". Usually this space is functionally obliterated by the position of the vagina, since the vagina in the usual situation is in an almost horizontal position (lying flat against the pelvic floor). Usually there is thus no real "space", just a potential one.

If for some reason this space opens up, it will immediately fill up with bowel loops, since it is situated low in the pelvis and the bowel loops will naturally move there under the influence of gravity. The most common reason for this to happen is a rotation of the vagina from its horizontal position to a more vertical position. This is usually the result of a weak pelvic floor.

An intact recto-vaginal septum is furthermore important to ensure the integrity of the separation between the intraabdominal cavity and the vagina. A torn or weakened fascia, especially the recto-vaginal septum, could lead to the formation of a hernia through the weakened upper part of the posterior vagina (back wall of the vagina).

Most people are aware of groin hernias, which form when the intraabdominal contents bulge through a weakened lower abdominal wall, causing a noticeable, uncomfortable and often painful swelling. These groin hernias may contain only fluid or fat, but sometimes they contain bowel loops. In the same way, a weakened posterior vaginal wall could lead to hernia formation. If the vagina is in the normal horizontal position, this will
not happen, since no forces are exerted on the posterior wall. If its axis changes, as described above, so that the forces of gravity are directed towards the posterior vagina, a weakened fascia (in this case recto-vaginal septum) leaves only a thin separation between the intra-abdominal contents and the vaginal cavity. The only remaining layers that then separate the inside of the vagina from the bowel loops are some fatty tissue, the vaginal mucosa, and the intraabdominal lining (peritoneum). In time this will stretch out and form a pouch that bulges into the top of the vagina. This might likewise contain only fluid or fat, but often it contains loops of small bowel. If severe, this hernia (called an enterocele), could fill the whole vagina and even bulge through the vaginal opening.

Since their origins are entirely different, it is important for the gynecologist to carefully distinguish between an enterocele and a rectocele during physical examination. Enteroceles are commonly missed during examination for genital prolapse and this could (not surprisingly) lead to early recurrence of prolapse problems after surgery.

Rectal prolapse:

Similar processes to those described above can lead to rectal prolapse. The normal rectal position is also dependent on intact pelvic support mechanisms, now familiar to the reader. Fortunately, it is the least common pelvic prolapse problem and if present it is usually minimal. It is almost uniformly associated with a degree of anal incontinence however.

III. Pelvic Floor Disorders

3) Genital prolapse:

Treatment options for genital prolapse:

As with urinary incontinence, treatment options include surgery or more conservative methods. Unfortunately, because of the severity of so much pelvic floor damage, weakness or dysfunction, conservative methods usually are used mostly to postpone the inevitable or for those cases where surgery is not possible or too risky.

Pelvic floor exercises:

Although many will disagree, I am of the opinion that pelvic floor exercises have little direct value in the treatment of moderate to severe genital prolapse. Since pelvic fascia tears and ligament weakness are almost always present, strengthening the pelvic muscles, even if possible, would contribute little to improving effective long-term support. This is different from urinary incontinence, where I believe strengthening the levator ani and sphincter muscles have more definite value and should usually be the first thing tried. Pelvic floor exercises are always a good idea however. Even if unhelpful in treating established prolapse, it might help prevent further deterioration, or other pelvic floor disorders from developing.

Pessaries:
These devices are placed in the vagina (see urinary incontinence) and although effective in some women, are not very popular. Reasons for this include the unfamiliarity with pessaries of many recently trained gynecologists, the reluctance of patients to accept them and more effective surgical treatments. In properly selected patients, pessaries can have a very significant and beneficial role to play. I am thinking here especially of the old and frail who might not be willing or able to safely undergo major surgery, and who have a relatively sedentary lifestyle.

Pessaries can also be used in pregnancy, especially during the early months of pregnancy if significant prolapse occurs before the natural enlargement of the uterus resolves the problem (often only temporary). Another place for pessaries is in the preoperative period, to help heal ulcers on the tip of the prolapsed cervix and to decrease the swelling of the prolapsed organs. Some women are so uncomfortable during this waiting period that a pessary could bring welcome temporary relief.

The choice of the correct type and size from the several types of pessary is more art than science, and experience is achieved only by trial and error. It often comes down to fitting various types and/or sizes to see which works best.

Surgery:

The mainstay of treatment for genital prolapse is surgery. The finer aspects of specific surgical procedures are beyond the scope of this manuscript, but I will try to explain some of the general concepts superficially.

Many gynecologists still believe, especially with regards to uterine prolapse, that simply to remove the offending organ will cure the problem. This may certainly be true in the immediate short-term, but there is an excellent chance that these patients will be back for further management of their ongoing, but now differently manifested, prolapse problems. Many of these physicians assume that the patient is suffering from a new problem, since he/she had after all successfully previously cured the patient of her uterine prolapse.

The fact is that the cause of the prolapse has to be identified and repaired at the time of initial surgery. It should be obvious by now what needs to be done. Of course - the pelvic fascia must be repaired where defective and the vagina must be suspended from secure structures for future support. After hysterectomy, the vaginal vault (that is, the vaginal roof, formed by suturing the cut surfaces of the vagina after removal of the uterus and cervix) needs to be attached to something, otherwise there is a risk of future prolapse, especially in the setting of pre-existent lack of support. Leaving it just hanging there without adequate support is to ask for trouble.

In cases of hysterectomies for reasons other than severe prolapse, the structures utilized for this suspension function are the so-called utero-sacral ligaments (see illustrations page 8 & 9). These ligaments are very important in the support of the uterus in all women and weakness could contribute to prolapse problems. In cases of hysterectomies performed for prolapse, these ligaments are thus unfortunately usually weak and insufficient to be utilized effectively as the only support of the vagina. If they were strong there would probably not have been a uterine prolapse in the first place. Many gynecologists, however, continue to use these structures as the only means to support the vaginal vault. It comes as no surprise then that the recurrence rate of vaginal prolapse is high after hysterectomies performedforuterine prolapse. Having said that, the utero-sacral ligaments are sometimes merely stretched out rather than inherently weak. In such cases, they can be shortened and used for support quite appropriately. It is, though, not always possible to gauge their strength accurately and whether they will stretch again or not.

As you will have deduced, the most commonly performed surgery for uterine prolapse is hysterectomy. In the absence of contraindications this can appropriately be done as a completely vaginal procedure with no abdominal incisions. To prevent future vaginal vault prolapse, one could utilize various techniques such as using other strong pelvic ligaments as strong points to which the vault could be tied. One of these procedures is
the so-called sacro-spinous ligament fixation (see illustrations). The sacro-spinous ligament is obviously used here as the strong point. Although this is a very effective method it does have disadvantages. It necessitates a slightly larger dissection in the pelvis with resultant risks and it does cause the vagina to be in a slightly off-center position, which might lead to future problems, including increased cystocele formation. It does restore the horizontal position of the vagina, albeit not anatomically exactly correct, which decreases the risk of future enterocele. Sacro-spinous ligament fixation has been found to have no significant influence on sexual function. This procedure has the potential to cure prolapse with preservation of the uterus and I have done this a number of times successfully. This procedure is in almost all cases combined with a repair of the recto-vaginal septum to cure or prevent a rectocele.

Surgical steps simplified:

The surgical steps for the repair of cystoceles and rectoceles are similar. The vaginal mucosa (vaginal skin) is opened, the fascia is repaired by suturing, after which the mucosa is trimmed and then resutured.

More recently, abdominal methods of repairing these two defects have become popular. These include the para-vaginal repair as described in the section on urinary incontinence.

Enteroceles are usually repaired at the time of rectocele repair. The hernia sack is opened, tied off and the opening through which the hernia occurred is repaired.

Vaginal vault prolapse can be repaired either by an abdominal operation, or vaginally as mentioned above. If an abdominal operation is elected, a synthetic material is commonly used to suture the vaginal vault to the sacral bone. Since the vagina is often too short to reach the sacrum, this synthetic material is used as a bridge between the two structures to which it is securely sutured. This effectively creates a very secure suspension of the vagina.

IV. Cesarean Section

"I was cesarean-born. You can't really tell. Although whenever I leave a house, I go out through a window 19."

Having read this far it should be obvious to the reader that one way to assure protection of the pelvic floor during childbirth is to have a cesarean birth.

I have mentioned the influence of pregnancy per se, as well as other lifestyle and aging related issues as having an effect on the pelvic floor. Having elective cesarean births do thus not absolutely guarantee a normal pelvic floor, although it makes normal pelvic floor function much more likely.

Throughout the world, however, there is pressure to decrease the cesarean section rate. It is felt that the cesarean rate has increased to unacceptable levels and as a result of unacceptable indications. Indeed, cesarean section has become an easy way out in many situations, which spares the caregiver from having to make difficult decisions based on sound knowledge and from having to possess skills that were previously regarded as essential. The danger exists that caregivers resort to cesarean section in cases of minimally abnormal labor when, in fact, vaginal birth could be successfully accomplished. Some of the reasons for this might be to hide a lack of knowledge, to satisfy minor logistical problems or inconveniences, to ensure daytime deliveries.

Another driving force behind the increasing cesarean section rate, is the litigation atmosphere, which pervades our society, and the mistaken belief that a bad outcome necessarily implies that someone was to blame. The public has the impression (partly created by the medical establishment, and partly by the media), that medical science has overcome clinical disease and reproductive problems to a degree that we can only wish
for. These raised expectations create a situation where anything other than the perfect baby, is just unacceptable. It should be obvious what impact this has had on obstetric practice.

One example is vaginal delivery after previous cesarean. It is now accepted that vaginal delivery after one or even two previous cesareans is possible and, indeed, is likely to be successful. There are however risks that should be addressed before a patient can make a fully informed decision. Vaginal birth after previous cesarean has again become a hot topic. Over the last decade the attitude towards VBAC (as vaginal birth after cesarean is usually referred to), has changed from "once a cesarean always a cesarean" to, in effect, "once a cesarean always a VBAC attempt". Over the last few years, concern about possible complications, especially uterine rupture, has diminished to an almost blasé attitude. Very recently however, there was a dramatic shift in editorials and opinions expressed in the obstetrical literature. Suddenly the risks of VBAC have been highlighted again, not least by the American College of Obstetricians and Gynecologists. Partly because of the inherent risks to patients and their unborn babies and partly due to legal risks, the pendulum is shortly due to swing back towards cesarean births as a valid choice after a previous cesarean.

An argument often used to discredit cesarean birth is that it is more hazardous and costly than vaginal birth. Many publications state, quite categorically, that women who undergo cesarean are at increased risk to develop postpartum depression and adaptation problems, such as bonding with their babies.

It is clear from all of this what is expected of women. "Natural child birth", more home-like hospital settings and even home births have made a strong comeback. The minimalist approach is held up by many lay publications about labor and delivery as the only acceptable way. Specialist obstetricians are often attacked for their high rates of intervention and "meddling".

I do agree, as I have said before, that minimal intervention in a normal labor situation is appropriate and indeed preferable. I have no problem with the concept of "natural childbirth" per se, and detest the use of cesarean section for mere convenience or bogus indications. I do not however see this as a contradiction of the following sentiments:

Elective cesarean birth performed for an acceptable indication, and with full patient consent, as well as knowledge of the benefits and risks, is a totally acceptable way to have a baby. In the absence of a solid indication elective cesarean, or any cesarean for that matter, is not acceptable.

I believe that protection of the pelvic floor is an acceptable indication for an elective cesarean and is in compliance with the above statement.

This statement would imply a fully informed patient who has weighed all the facts, including the possible risks and complications, before she makes an informed decision. In my opinion, the moment a patient enters labor with the intention of having a vaginal delivery, protection of the pelvic floor, as an indication for cesarean, falls away completely and permanently. To resort to this indication at a later stage during labor would, in my view, be an inappropriate attempt to justify doing a cesarean section for the sake of convenience in the absence of another solid indication. This is thus not something that should be discussed during labor, but rather during pregnancy, when there is enough time to weigh all the consequences rationally.

Now let us look at the cesarean section in more detail.

19. Quote by Stephen Wright. "Roasts & Toasts" Gene Perret and Terry Perret Martin. Stirling Publishing Co.

IV. Cesarean Section

History of Cesarean Section:

The origin of the word cesarean, or caesarian (British spelling), is doubtful. The word is rumored to have originated from Julius Caesar, who it is believed, was the first live infant born by this method (in 100 B.C.). This is very doubtful, especially in light of the fact that his mother Aurelia survived his birth, and that written history contains no record of such an event. In fact, Aurelia was still alive when Caesar was 48 years old and reducing Gaul to a Roman province. Her survival is almost certainly incompatible with a cesarean birth, since the maternal mortality (death rate) after cesarean was almost a hundred percent until the early part of this century.

It is almost impossible for us to understand the fear, horror and revulsion that the concept of cesarean birth engendered until relatively recently. To try and understand the history of this operation previously known as the delivery of a child "per viam non naturalem" (by non-natural route), one has to understand something about the surgical practices of previous times. Until early this century the procedure was usually performed without any anesthetic whatsoever. Four or five men would hold the woman down on a table (often a kitchen table), while the surgeon would cut into her abdomen with a dirty kitchen or pocketknife or sometimes a razor blade. This knife or blade was often caked with old blood and grime, while the surgeon's hands were often even dirtier. Surgeons would walk from patient to patient, and even from corpses to patients, without washing their hands. Their status was to some degree dependent on the built-up gore and blood on their coats. The most important criterion distinguishing a good surgeon from a bad one was the speed at which the particular operation could be performed. The lack of effective and safe anesthetics makes this understandable and logical, but it doesn't however lend itself to the development of safe and anatomically correct surgical practices.

Until early this century the surgeon would cut through the abdominal wall and through the uterus, would pull the baby out and then sew theskin incisionbut leave the underlying tissues, including the uterine incision, open. Women almost invariably bled to death, and those few, who survived this stage of the operation, later almost certainly succumbed from overwhelming infection. Remember that antibiotics only date from the 1930s.

As a result of the exceedingly poor maternal outcome, the procedure was usually only performed after the death of the mother or when she was definitely at death's door. In the Roman Empire the division of the so-called "Justinian Corpus Juris" contained the "Rex Regia" law. This law, enacted by the second king of Rome, Numa Pompilius (715-673 B.C.), stated that it was forbidden to bury a dead pregnant woman before the fetus has been removed;"Negat lex regia mulierem quae praegnans motua sit, humari". This was also the practice in India, Arabia and Persia and possibly even in early Egypt.

In 1609 Guillemeau, writing of the "happy deliverie of women", notes that"Lawiers judge them worthy of death, who shall burie a great bellyed-woman that is dead, before the child be taken foorth". He then goes on to speak of the haste needed to save the baby, but also about the need to ensure that the woman is dead and that"her kinsfolkes, friends and others that are present, do all affirme and confesse, that her Soule is departed". He himself had twice performed cesarean sections on living mothers, and had seen three more done by three Paris surgeons. All the women died. Nevertheless there are some occasional reports of women surviving their ordeals and even going on to deliver babies vaginally later. In the 18th century 36 living infants were reported to have been delivered by cesarean after their mothers' deaths, and by the mid-19th century, over 80 more such cases had been reported. Before 1700, assessments are difficult since the Lazarus-like accounts of living babies rescued from their dead mothers' wombs, some buried for days, strain the credibility of even the most gullible.

Even Shakespeare took note of this interesting operation, in Macbeth, when he writes"Macduff was from his mother's womb untimely ripped".

The earliest account of this procedure in any medical textbook of importance appeared about the year 1350, where it is noted to be a proper procedure after the death of the mother. The oldest authentic record of a living child born by cesarean, however, is that of Gorgias, the celebrated orator of Sicily in 508 B.C. Another early cesarean survivor was Scipio Africanus (born in 237 B.C., and also called "Caesar"), the conqueror of Hannibal. His birth was recorded by Gaius Plinius the Elder in his"Historia Naturalis". He wrote: "Auspicius enecta parente gignuntur; sicut Scipio Africanus prior natus, primusque caesarum, a caeso matris utero dictus: qua de causa et caesones appellati. Simili modo natus est Manilius qui Carthaginem cum wxercitu intravit."

Greek mythology contains some references to such an unnatural birth. Asclepios, the tutelary god of medicine, was delivered from his mother Coronis in this manner:"Natum flammis uteroque parentis eripuit geminique tulit Chironis in antrum". (He snatched his son from his mother's womb, says Ovid, saved him from the flames, and carried him to the cave of the centaur, Chiron). Hermes was the alleged surgeon after Coronis had been killed by her husband Apollo's sister, Artemis.

Although this operation is mentioned in the Talmud and in the Veda books of India, some noted physicians of antiquity do not even mention it in their works. Aulus Aurelius Cornelius Celsus does not mention the operation in books vii and viii of his"de Medicina"which deal with surgical treatment. Similarly Soranus of Ephesus, regarded as the greatest obstetrician and gynecologist of antiquity, who lived from 98 to 138 AD, and whose published works commanded the utmost respect for 1500 years, did not mention the cesarean method of delivery. Other important obstetricians, among them Aetius of Amida and Paulus Aegineta, who both published important obstetrical works, were silent on the topic. That such eminent physicians of the time ignored the operation suggests that it was an extremely rare occurrence and that it was not part of practical obstetrics. It may also be that the medical politics of the time, or disdain for the almost uniformly poor outcome of the surgery, led to a conscious choice to exclude the topic.

As mentioned the origin of the word "caesarian" is very uncertain and it is unlikely that there will ever be a unanimous opinion. I already mentioned that Julius Caesar was unlikely to have been born by "caesarian". The word further pre-dates him by centuries, since Scipio Africanus was also named "Caesar" and Pliny's "Natural History" records a Caesar before the Samnite wars in about 340 B.C. Gaius Pliny the Elder was the first to use the termCaesonisindicating "one cut from his mother's womb" and, in this respect, Scipio Africanus could be said to be the first Caesar.

The derivation of the term is unclear however, and several far-fetched theories have been suggested. These range fromcaesa, which means "elephant", in the Moorish and Punic languages (Julius Caesar was a large man), tocaesaries,(a bushy head of hair), to caesius, (to have blue-grey eyes). In Roman use, the termCaedereindicated killing, slaying or destroying on a grand scale (which could easily be understood to be associated with the "Caesar"), whereassecareorincideremeant to cut or incise. After the murder of Julius Caesar (definitely acaedes), his assassins took on the name Caesar, thus belying any supposed connection between the name and any specific manner of birth quite convincingly.

Further picking at the word caesarian reveals other interesting meanings.Caesarianusmeans belonging to Caesar, whereascaesariatusmeans long-haired.Caesareusalso depicts an ownership of, or being part of Caesar.

It was the Jesuit, Théophile Raynaud, who first used the term caesareus in the title of his book, which was the first to be written on the "caesarean" operation. François Rousset gave the first verifiable account of a successful cesarean section, which resulted in the survival not only of the child, but also of the mother, sometime in the 1500s, although he called the operation a"hysterotomotokie". This term is more in line with current use of the term"hysterotomy", which is a similar operation to a cesarean but done for a non-viable fetus, oranyincision into the uterine cavity, even in the non-pregnant woman. Anyway, this"hysterotomotokie"was performed by none other than a sow-gelder, named Jacob Nufer of Siegertshaufen, which is about 20 kilometers south-west of Augsburg, Germany. He did this around 1500 AD on his own wife, and used a razor blade. Apparently she had been in labor for many days, and over a dozen midwives and barbers had failed to deliver the baby. Even though his wife was in favor of the attempt, since she believed that she was dying anyway, the authorities turned deaf ears to his petitions. Nufer, in desperation, proceeded anyway. After laying her on a table with the necessary attendants to hold her down, Nufer made the incision, extracted the child and apparently sutured the abdominal wall. Almost miraculously his wife recovered, but just as remarkably went on to bear twins at a later date and four more children, all of whom were delivered normally.

Although the operation was repeated intermittently through the following centuries in different countries, it was always done as a last resort on a living mother. As a result of the extremely high maternal mortality, most eminent obstetricians not only frowned on the procedure but also openly condemned it, so no progress or uniformity of technique was achieved. There was even an active anti-cesarean movement, called "Ecole anti-Cesarienne" led by Sacombe in post-revolution France.

As is common with most human endeavors, jealousy and rivalry enter into the history of this remarkable operation. Although it is widely believed that Jesse Bennett of Mason County, West Virginia, performed the second wholly successful cesarean in the world and the first in the New World in 1794 (again on his own wife), this same honor is also claimed for John Lambert Richmond (near Cincinnati, Ohio) for 1827. Other claims place this second event in Martinique, of all places, in 1805.

The accounts and assessments of Bennett's operation contain allegations of fraud, intrigue and all the necessary ingredients for a good story. For one thing, it is alleged he graduated from the University of Pennsylvania, but apparently there are no records of any such graduation. The accounts of the operation and of Bennett's life supposedly hinge on the article by A.L. Knight entitled "The Life and Times of Jesse Bennett, M.D.". This was published 50 years after Bennett's death and the only source of information was apparently what either Bennett or his sister in-law, Mrs. Nancy Hawkins, had told Knight at least 53 years earlier. This would have made A.L. Knight between fourteen and eighteen years old!

Each individual country has divergent histories about the progress of the operation before this century. So for instance, in Great Britain the first operation of this kind, where the life of the mother was saved, was performed by a surgeon, James Barlow of Lancashire, while he worked in Chorley in 1793. In Sweden, the first recorded cesarean section was performed in 1360 A.D.. This section was performed post-mortem, thus after the death of the mother. During the years 1758-1875, 13 cesarean sections were performed in Sweden. All of these women died. During 1882-1890, 13 more cesarean sections were performed using a new method and with the loss of about 54 percent of the women. The first cesarean on a living woman in Australia was performed in 1872, and, in South Africa, sometime between 1815 and 1821. The South African child, James Barry Munnik, survived, and his grandson, James Barry Munnik Hertzog (1866-1942), later became the Prime Minister of South Africa from 1924 to 1939.

During the subsequent decades tremendous medical advances were made in the fields of microbiology, which led to increasingly effective antiseptic technique, surgical technique and anesthetics. As the figures for maternal mortality after cesarean section plummeted, the procedure became more accepted and established.

IV. Cesarean Section

Risks of cesarean birth:

Many articles have been written to compare the safety of cesarean birth with vaginal delivery. Most of these are somewhat dated, but they found cesarean section to be the more hazardous option. Consensus opinion estimated the mortality risk to be two and five times higher for cesarean section than for vaginal delivery. The published absolute mortality rates per 1000 cesarean births vary from 0.4 in the Netherlands, 0.5 in Denmark, 0.0-1.0 in the USA and 0.8 in England and Wales. This means four maternal deaths per 10,000 cesareans in the Netherlands, five per 10,000 in Denmark, zero to ten in the USA and eight in England and Wales. Most of this data is from the '60s and '70s, however, and is thus questionable. Frigoletto et al reported the performance of 10,231 cesarean sections in Boston Woman's Hospital between the years 1968-1978 without a single maternal death. 20 In comparison to the above, appendectomy operations have a published case fatality rate of 4.3-4.8 per thousand operations.

The mortality rate of cesarean sections can also be placed in perspective if it is compared to mortality from motor vehicle accidents in women aged 15 – 34. This was about 0.2 per thousand women per year in the US in 1985 (two out of every 10,000 per year of road use, thus, every year). There is little reason to believe that this situation has improved, and it might even have worsened.

A) Anesthetic complications:

One of the major problems with emergency cesarean section is the fact that patients do not have empty stomachs. They have either eaten, drank fluids or both, relatively shortly before the surgery becomes necessary. A full stomach is one of the most serious risk factors for general anesthetics, and in most non-emergency situations anesthetists would postpone the surgery. The problem is that there is an increased risk of inhalation (breathing in) of stomach content, which is an extremely dangerous situation. With an elective cesarean birth, the patients are fasting, and although the risk for having increased stomach content is higher than in a fasting non-pregnant woman, the risk is much reduced.

Further developments over the last decade include greater experience with epidural and spinal anesthesia. Spinal anesthesia is a reliable and easily learned anesthetic technique. It works quickly, provides a dense block and involves only a single quick injection into the cerebrospinal fluid (fluid column surrounding the spinal nerves). In my opinion it is by far the preferred method.

Unfortunately, the more common epidural anesthesia has multiple disadvantages compared to spinal anesthesia. First of all, it takes a long time to work, it might not work at all or not provide a block which is dense and equal enough, and so a higher dose of local anesthetic is used with more associated risks of toxicity. With both these methods the patient stays awake although, if preferred she can be heavily sedated. A "significant other" is commonly allowed to sit with her, to share in the experience and provide support.

In comparison to a general anesthetic, spinal anesthesia is definitely preferable and as a general rule, general anesthesia should be used only as an exception.

Potential side effects and complications of spinal anesthesia:

1) Postdural puncture headache (spinal headache).

This distressing problem is a result of a slow leakage of spinal fluid from the puncture site. In its mild form it is a nuisance only; but in its more severe presentations it can be disabling, and the sufferer is forced to stay flat on her back. Lying down relieves this headache almost immediately, for reasons that are well known, but fall outside of the scope of our discussion. The risk of this problem is approximately one percent. One has to keep in mind however that the same risk exists for epidurals. Although the absolute risk in epidurals is somewhat lower, since the needle in an epidural should not penetrate completely into the spinal fluid column, if it does occur, chances are that the degree of headache will be worse. The reason for this is the thicker needle used for epidural establishment. One should consider the fact that, in some areas, between 30 and 50 percent of women in labor with expectations of vaginal birth, receive epidural anesthetics.

2) Nerve damage.

This major complication is fortunately extremely rare, and also occurs with epidurals. A study published in 1995 by Scott and Tunstall reported 46 cases of neurological complications after 122,989 spinal and epidural anesthetics21. There were no reports of permanent disability, however, and complete recovery occurred in all cases.

3) High block.

This rare, but serious, complication involves a rising level of nerve blockage, which could eventually cause loss of consciousness, and is potentially life threatening. As long as the problem is recognized in good time the anesthetic could be converted to a full general anesthetic and the necessary resuscitation measures instituted. The important thing here, obviously, is to have an adequately trained anesthetist.

4) Backache.

There seems to be no evidence of a relationship between spinal anesthesia and long-term backache.

5) Infection and hematoma.

Although potentially serious, this is fortunately rare. A serious infection after a spinal anesthetic might potentially lead to meningitis. Hematoma (blood clot) formation could potentially cause pressure on the spinal canal. This extremely rare complication has been found in approximately one in 505,000 epidurals. The risk is even lower in spinals as a result of the thinner needle used.

6) Shivering and itching.

Again, these symptoms occur in both spinals and epidurals, but are less likely to occur in spinal anesthesia. The exact cause is unknown, but it also occurs in about 10 percent ofnormallabors. The itching is a result of histamine release due to opioids (medications similar to morphine), which are added to the blocking agent to provide postoperative pain relief and to reduce the dose of blocking agent needed for adequate anesthesia. Interestingly, many women complain of itching of their nose tips.

7) Drop in blood pressure.
This common occurrence can be prevented ,or rapidly treated, if diagnosed early. It results from the opening up of large numbers of small blood vessels in the areas of the body that are blocked (lower body). These blood vessels normally have an inherent tone (continuous state of contraction keeping their diameters small), which is lost as a result of the blockage of their own small nerves. As a result of the sudden opening up of millions of small vessels, the average pressure in the vascular system drops. It is for this reason that most anesthetists will "top up" the fluid volume in a patient's vascular system by giving intravenous fluids before doing the spinal or epidural. Again choosing an anesthetist with adequate experience and training cannot be stressed enough.

21. Scott DB, Tunstall ME. Serious complications associated with epidural/spinal blockade in obstetrics: a two-year prospective study. Int J Obstet Anesth 1995;4:133-9.

IV. Cesarean Section

Risks of cesarean birth:

B) Infection:

I am sure I do not have to inform the reader that infection is a possible complication of any operation. Since we are dealing with elective surgery, however, this becomes an important factor to consider. One of the reasons for maternal deaths in the various studies was severe infection. These could be wound infections, intrauterine infections, pneumonia or various other infections. As already mentioned, keep in mind that these studies lumped together all cesarean sections, regardless of the indication. A large percentage of these had risk factors for infections which makes the data invalid if looking at elective cesareans only. One of the well-known high risk factors for infection after vaginal or cesarean birth is having ruptured membranes for a long time ("ruptured membranes" means the water has broken, something that often occurs early in labor, either spontaneously, or induced). This creates an open passage from the vulva and vagina to the uterus. Every instrumentation and vaginal examination increases the risk of infection as a result of bacteria being pushed into the uterine cavity. Cesareans done after prolonged labor thus differ in a substantial way from the electively performed procedure with intact membranes.

Most women who consider an elective cesarean section for protection of their pelvic floor would not be likely to have serious medical or obstetrical complications, as these would become the overriding factors to direct the care and decisions made. Although there is little data to prove the point, it is logical to assume that these healthy patients would have a substantially lower risk of infection. Since spinal anesthesia is the preferred method, the risk of pneumonia can be substantially reduced as well. Pneumonia is a significant risk of general anesthetic, as a result of the potential inhalation of stomach content, as well as the mechanical ventilation (mechanical breathing) employed during the general anesthetic.

It has been adequately proven that a dose of antibiotics reduces the risk of infection after cesarean. Although not routinely given to all cesareans by every obstetrician, it has been shown to make a significant difference even in the elective case. I would thus recommend a single dose of intravenous antibiotics during the operation immediately after the baby is delivered. Giving it at that point prevents the baby from being exposed. Concern might arise about this apparent increase in antibiotic use. In my opinion this is a non-issue. Current recommendations in North America, which are practiced throughout the world, mean that approximately 40 percent of normally laboring women receive intravenous antibiotics during labor. The reason for the application of antibiotics is to attempt to prevent a serious infection caused by a certain organism called Group B Streptococcus. This organism has the potential to cause severe maternal infection, and moreover, to severely affect the newborn baby. It is recommended that all screen positive women or all women with risk factors for this problem should receive antibiotics in labor. Since approximately 40 percent of women are colonized with this organism in their vaginas, they should thus be given antibiotics. Antibiotics are given throughout labor and multiple doses are thus usually employed to which the babies are obviously exposed. Other pregnant women who routinely receive antibiotics are those who go into premature labor. It is thus obvious that the use of antibiotics in pregnancy and labor is very common, and the application of a single prophylactic preoperative dose before elective cesarean birth might in reality decrease the total antibiotic dosage exposure, given a large enough cesarean birth rate.

Concern has been expressed over the last number of years about the potential increase of organisms that are resistant to multiple antibiotics. This is certainly of great concern not only to obstetricians but also to all physicians. Fortunately this has not yet become a widespread problem. As argued above, higher numbers of elective cesareans will make no substantial difference to the induction of antibiotic resistance and may even have a paradoxical protective effect. Since the numbers will be relatively small in relation to the overall birth rate, however, I anticipate that there will be no real impact.

Infection with resistant organisms after cesarean birth is of more concern. The same could be said foranysurgery, especially surgery that has no immediate life threatening indications. Indeed, if this argument is used to restrict elective cesarean births, other commonly performed elective surgeries would be equally unjustifiable. For the time being, at any rate, this need not be a major concern in the decision-making process. Physicians should be aware of the incidence of these organisms in their specific hospitals and this is something that needs to be discussed between the patient and her physician. Recent and foreseen future breakthroughs in ways to overcome the penicillin resistance of some bacteria, might again make this less of a concern.

C) Thromboembolic problems:

As a surgeon, it often amazes me how any human being manages to be alive at all. The fragility of our connective tissues, especially in relation to blood vessels and to our thin-walled veins, is a constant reminder to me of our mortality and the thin line between life and death. The integrity of our blood vessels prevents us from bleeding to death, and equally important are the intactness of our blood clotting mechanisms. Without this finely balanced and fascinating system, we would either instantaneously bleed from every pore, or our blood would immediately coalesce into a firm and gel-like clot. Neither of these scenarios is compatible with life.

The clotting mechanism, simplistically, consists of the functions of platelets, the clotting factors, fibrinogen as well as various anti-clotting agents. It is obvious that these pro-clotting and anti-clotting factors must keep a delicate balance, to prevent inappropriate clotting, but at the same time must protect us from exsanguinating (bleeding to death) in the event of tissue injury. This balance can be influenced by many different causes, the most well known of which is smoking (smoking has a pro-clotting effect). Various diseases and genetically determined disorders can also influence this system.

The pregnant woman is at substantially increased risk of thromboembolic events as a result of the physiological changes in the blood clotting mechanisms that are associated with pregnancy. Blood clots in the legs, called deep vein thrombosis and even clots in the lungs, called pulmonary embolisms, are serious events that occur more frequently in the pregnant, than in the non-pregnant, population. This increased risk is mostly due to a significant increase in many of the pro-clotting factors and fibrinogen in pregnancy. There are also certain well-known medical conditions that increase this risk even further. Unfortunately these conditions are often not known to be present until unmasked by an acute thrombotic event. Major surgery, such as a cesarean, increases the risk.

Immobilization is well known to be a major causal factor involved in thrombosis, especially after surgery. As a factor it compares very differently between the elective cesarean birth for healthy women, to those women who undergo an emergency cesarean section after a prolonged labor during which they were confined to bed. These emergency cases are often dehydrated as a result of insufficient intake, and of the increased fluid loss during the rapid breathing and intensive muscle action which usually accompany labor. In the elective case, the patient is usually healthy, was mobile immediately prior to the procedure and although having fasted for a pre-determined period of time, usually not dehydrated. Any anesthetist worth his salt will replenish the patient's intravascular volume to ensure she is not dehydrated. Since the elective cesarean patients are usually less tired than those who underwent emergency surgery, as well as the fact that these would be well motivated and fully informed patients, it is usually easier to motivate the elective cases to mobilize (get out of bed) after cesarean.

Since immobilization and dehydration are two of the most serious risk factors for thrombosis, I believe that the risk for healthy women having an elective cesarean birth is significantly lower than the level published in most articles. As mentioned before, these articles do not take into consideration the differences between the elective cases and the emergency ones. I suspect these differences to be so great as to almost make comparisons and extrapolations invalid.

Preventing thromboembolic complications of surgery has become an important aspect of preoperative as well as postoperative care of all surgical patients. In gynecological surgery, general surgery and orthopedic surgery the risk is especially high and steps are taken according to certain protocols and indications to lower that risk. In most cases where patients are deemed to be at higher risk, methods employed might include stockings, leg bandaging, automatic compression stockings or Heparin. Heparin is a drug used to prevent as well as treat blood clots. The drug is most often given as subcutaneous injections (superficial skin injections) prior to or immediately after surgery, and usually for as long as the patient is immobilized. It is well known that this drug does not cross the placenta and thus would not effect the fetus in any way. The older, standard type of Heparin has been used extensively in pregnancy, for prolonged periods and for various indications, with no fetal problems. Less data is available about newer formulations (called: Low Molecular Weight Heparin), although they are being used in pregnancy more and more, and we know that they also do not cross the placenta. All indications are that they are equally safe and they are rapidly becoming the drugs of choice.

Given the increased risk of thromboembolism in pregnancy, it is surprising that it is not standard practice to take specific preventive measures during and after cesarean section. Possible methods include bandaging, stockings or the employment of Heparin, either before or immediately after the cesarean section. I feel that employing Heparin for post-cesarean prophylaxis (prevention) should be considered for postoperative care in all cesarean patients. We know it is effective, and since we know these patients have an elevated risk for thrombosis, it makes no sense not to consider it. Unfortunately, as with all things in medicine, there are possible risks, among which are bleeding complications. With the new "Low Molecular Weight" Heparins this risk is seems to be reduced, except for a recognized risk for spinal hematomas. They should thus only be utilized starting about 24 hours post spinal, with standard Heparin in the interim.

Patients are also urged to get up as soon as possible after their operation, and to mobilize as soon as possible. The use of spinal anesthesia helps in this regard, especially if a long-acting opioid (for instance morphine) is added. The resultant decrease in pain for the first 24 hours helps to get patients out of bed and moving. Better and deeper breathing as a result of decreased pain helps significantly to increase effective blood flow from the lower body to the chest and heart from where it is again circulated.

IV. Cesarean Section

Risks of cesarean birth:

D) Bleeding:

Another of the possible major complications during or after a cesarean section is that of hemorrhage. The average blood loss during routine cesareans is usually estimated at around 700 milliliters to one liter. In the normal non-pregnant patient, this would be a significant percentage of total blood volume. The pregnant woman however, has significant physiological adaptations protecting her against complications of significant blood loss. Normal vaginal delivery causes an average loss of around 500 milliliters (half a liter) of blood with usually no negative effect. The reason that pregnant women can withstand the loss of this amount of blood, without suffering the usual consequences, is that the hormones of pregnancy have caused a significant increase in blood volume. This increase is around 40 percent of total blood volume. Another adaptation is a greater, percentage-wise, increase in blood plasma over the red blood cell number. As a result, for any given volume of blood the pregnant woman has fewer red blood cells than the non-pregnant woman, even though she has an increased number in total. The loss of a certain volume of blood thus leads to the loss of fewer cells than would have occurred without this dilutional effect.

Postpartum bleeding most commonly occurs as a result of a relaxing uterus. This is as true for a post-cesarean patient as for one who has had a vaginal delivery. The reason is the following: during pregnancy the blood flow through the uterus which supplies the nutrients and oxygen to the placenta and to the fetus is incredible. Almost the whole blood volume of the pregnant woman at term (towards the end of pregnancy) circulates through her uterus every few minutes. This blood flows through open vascular canals to the placenta and then back into the mother's circulation. After separation of the placenta from the uterus, it is thus imperative that the flow be cut off almost instantaneously to prevent the otherwise inevitable death in a few short minutes. Anyone who has ever bled from a wound (and that probably includes everybody) will agree that the normal way that bleeding stops in a wound will not suffice. The normal clotting mechanisms, which come into play to slow bleeding under these conditions, are far too slow. It is indeed true that nature has devised an ingenious way to stop the bleeding from the postpartum uterus, almost like turning off a tap.

The uterine muscles form an intricate network of muscle fibers weaving their way around the blood vessels and channels. Contractions of the uterus have the ability to cut off bleeding by instantaneously restricting thin walled channels. During labor, this safety mechanism can sometimes cause problems with decreased blood flow to the fetus. As a mechanism to stop the postpartum bleeding, however, it is an effective and absolutely crucial occurrence. Any relaxation of the uterus after delivery usually leads to bleeding. Unfortunately the uterus is somewhat more prone to relaxing after cesarean than after normal delivery. Obstetricians are very aware of this fact and will usually take adequate precautions. The risk of relaxation of the uterus (also called uterine atony) is also significantly less after elective cesarean, than after a cesarean performed after many hours of obstructed labor, where the uterus is simply worn out.

Although the blood loss during cesarean section can be double that lost during normal vaginal delivery, it is usually not clinically important and blood transfusion is very seldom necessary.

Any patient with bleeding disorders, or with medical or obstetrical conditions that make dangerous bleeding more likely, should obviously be carefully counseled an informed and might not be candidates for elective cesarean. It also stands to reason that a woman contemplating cesarean should be in the best medical condition possible, and that obviously must include the absence of preventable anemia (abnormally low blood count, usually related to lack of iron).

E) Surgical injuries:

Most surgical procedures carry an inherent risk of injuries to organs not usually directly involved in the particular surgery and cesarean is no exception. Injuries to bowel, bladder, ureters and blood vessels have all been described. Fortunately these injuries are rare. The most common injury would to the bladder. This usually occurs either upon entering the abdominal cavity, or when freeing the bladder from the lower segment of the uterus (see: cesarean technique). Fortunately these injuries are usually very easily dealt with via simple sutures and keeping the bladder empty with a catheter. Injuries to bowel or ureters could potentially be more serious especially if overlooked.

I firmly believe that the incidence of injuries during elective cesarean will be found to be lower than during emergency cesarean. This makes logical sense in that an elective cesarean is, by definition, a more relaxed procedure usually performed with less haste. The fetal head is usually higher in the pelvis and not wedged tightly as in so many cases where cesareans are performed during labor. Injuries often occur in the process of delivering such wedged babies.

A repeat cesarean, exactly like a repeat abdominal operation for any other reason, is technically somewhat more difficult and carries a slightly higher risk for complications. Usually this is not a problem however. A good surgical technique and meticulous care during the performance of the surgery will minimize the potential risk. Although this risk can never be zero, even in the best hands, incidental injuries during cesareans really are very uncommon.

F) Psychological problems, bonding problems and postpartum depression:

I have mentioned previously that it seems as if there might be an increased incidence of depression, or maladaptation and abnormal bonding with the baby after cesarean. I strongly believe however, that to see this merely as a complication of cesarean section is a simplistic generalization and wrong. Some of my most ecstatic and well-adapted patients and new mothers had their babies by cesarean birth.

There are many factors that could play a role in this regard and, of course, every patient's expectations are different. The reaction of any specific patient cannot be known beforehand, but I do believe there are a few general truths. Any patient that has been brainwashed into believing that vaginal birth is the only acceptable way to have a baby, and that any other way would indicate a failure of herself as a woman and a mother, can be expected to be upset, disappointed or even pathologically depressed after having undergone a cesarean section. In comparison, it follows that the woman who has considered all her options carefully and who has come to the conclusion that cesarean birth would be best, is certainly less likely to have these emotional problems. To expect increased emotional difficulty after cesarean simply related to the mode of delivery is thus simplistic and it may become a self-fulfilling prophecy. It all revolves around expectations, beliefs and even peer pressure.

In my view the birth of a baby, in itself, is such an emotional and overwhelming occurrence that the route of delivery is of lesser importance. No one can deny, however, that the feeling of accomplishment after the vaginal delivery of a baby after labor will be lacking in cesarean births. This feeling can sometimes be an almost overwhelmingly positive sensation that reaffirms the woman's strength, womanhood and ability to bring to a conclusion this most important biological aspect of being a woman. It is thus possible that even the well-informed and well-prepared woman delivered by cesarean, might feel some regret later on. This is one of the important reasons I believe that the decision to have an elective cesarean birth should only be taken after a process of discussion, and evaluation of the facts and risks. The patient's own specific emotional needs should not be neglected and, as I have stressed before, this is not a decision that should be made during labor.

G) Intra-abdominal adhesions:

Any abdominal surgery can potentially lead to adhesion formation inside the abdominal cavity and cesarean section is no exception. These adhesions sometimes present soon after the surgery with symptoms of bowel obstruction, but the more common scenario is that of delayed presentation at a time remote from that of the surgery. These adhesions can also present with abdominal pain when they interfere with other organs, but the most common presentation by far is acute or subacute (partial) bowel obstruction. Further surgery is then indicated, often as an emergency procedure, which can then lead to an exacerbation of the adhesion formation process.

Fortunately, cesarean sections do not often lead to adhesions causing bowel obstruction. Although adhesions are not uncommon, they more frequently occur in front of the uterus and most commonly involve the bladder. The most likely clinical significance of post-cesarean adhesions is that they could make the next cesarean more difficult and as a result increase the probability of operative complications, especially bladder injuries. This is one of the reasons that the risks of elective cesarean will probably outweigh the benefits in women planning many (more than three) children.

Adhesions from previous major abdominal surgery could potentially interfere with the function of the fallopian tubes and thus lead to infertility problems. This is a particularly unlikely complication of an uncomplicated cesarean section however.

H) Placenta accreta:

Placenta accreta is a condition that fortunately is quite rare, since it can have devastating consequences for the future reproductive career of a woman and can cause one of the most serious obstetrical emergencies, usually immediately after childbirth. It should be noted that I said "childbirth" and not "cesarean birth". The reason is that this problem is not exclusive to cesarean but is a potential complication of any birth. Most cases occur after vaginal delivery but that is likely only true because most births are vaginal. It is a similar situation to that of Down syndrome, where although the incidence rises rapidly with maternal age, most Down syndrome babies are born to young women in their twenties. This is because most babies are still born to younger women (this might change in the future if the demographical shift previously described increases with a further propensity towards later childbirth).

Having said this, there is no denying the fact that cesarean increases the risk of placenta accreta, especially if the placenta is low lying in the general area of the previous uterine incision. By now I am sure you are feeling like crying out " now what in heaven's name is this beast?" "Placenta accreta" literally means "stuck placenta". This occurs if the placenta is abnormally attached to the uterine wall with the result that it cannot release after childbirth. The results can be dramatic with severe hemorrhage the possible result of attempts to removing the placenta. A hysterectomy is sometimes the only way to deal with the situation.

"Placenta previa", means a placenta that is in front of the birth canal opening. In practical terms this means that the placenta is blocking the inner cervix through which the baby thus cannot pass in order to be born. Partial placenta previas are often detected by an early ultrasound. As the result of later development of the lower segment of the uterus lower than the placenta, later ultrasounds usually find a significantly reduced number of placenta previas. A more complete covering of the cervix by the placenta is however unlikely to resolve. The underlying problem is an implantation of the placenta in an abnormally low position in the uterus. In case of a previous cesarean section, the finding of placenta previa, especially if the placenta is located towards the anterior (front) part of the uterus, raises concern of a placenta accreta. It is thought that the scar formation leads to an abnormal placental attachment. In these cases, the placenta in actual fact grows into the wall of the uterus with the resultant failure of the detachment mechanisms after birth. Attempts to remove it might only cause its piecemeal removal, with heavy bleeding as the result. As mentioned, emergency surgery is sometimes necessary.

Although the incidence of placenta accreta is higher after previous cesarean births, the actual overall incidence is low. Ultrasound exclusion of a low lying placenta over the anterior part of lower segment (thus directly underlying the previous cesarean scar), makes it very unlikely indeed

IV. Cesarean Section

Technique of cesarean section:

I was recently asked a question by a patient that made me realize once more how many misconceptions abound relating to various medical interventions. The patient asked me how long her cut abdominal muscles would take to heal. As I was already busy working on this manuscript, the question was quite an eye-opener. I immediately decided that a short section explaining the technique of a cesarean section was imperative.

The answer to the above question is that no abdominal muscles are in fact cut. The only muscle that is cut is that of the uterus. The steps in a cesarean are basically (with some minor variation) as follows:

The skin of the lower abdominal wall is incised in a transverse direction just above the pubic hairline in the majority of cases (side to side rather than up and down). A longitudinal (up and down) incision is infrequently employed. Just under the skin, a layer of fat is found which is easily separated to reach the next layer. The reader will recognize this next type of layer since it is a dense shiny white layer of fascia called the rectus fascia. Like the pelvic fascia this is a connective tissue layer, which surrounds the rectus abdominal muscles and offers support, attachment and strength. This fascia layer is incised to expose the two rectus abdominal muscles which are big muscles running from the rib cage to the pubic bone. These are the main muscles employed to do sit-ups. The two muscles meet in the midline where they are sometimes fused but quite often, however, they are separated as the result of the stretching from the distended uterus. These muscles are now separated (without cutting them) and pulled to the sides to create a space between them.

After this space has been created, the only layers covering the uterus are thin fascia and the peritoneum. The peritoneal layer is a very thin membrane-like layer, which can be described as the lining of the abdominal cavity. After this layer is penetrated the uterus will lie directly in view. A second layer of peritoneum, which is also incised and pushed out of the way, usually covers the so-called lower segment of the uterus where the incision will be made. This simple, but essential part of a cesarean section, helps to prevent injuries to the bladder, which lies on top of the lowest part of the uterus and the immediate vagina.

After the bladder has been pushed to safety the next step is to incise the uterus. The incision in the uterine wall is also made transversely and it is made in the lower segment of the uterus, just above the cervix, which is the thinnest part. The incision is usually started with a scalpel but usually completed by manual stretching. This is done to prevent injury to the immediately underlying infant. The baby is then delivered by guiding its head into the opening with one hand while the assistant exerts pressure on the uterine fundus (top of the uterus).

After delivery of the baby it is handed to the pediatrician, after which the placenta is removed by manually grasping it and pulling it through the incision. At this point the antibiotic as well as a drug to ensure contraction of the uterus (Oxytocin) is usually administrated by the anesthetist. Suturing of the uterine incision commences immediately and can be done in one or more layers. The peritoneal layers can be sutured or left open. I personally am of the school that believes that there is no benefit in suturing the peritoneum in most cases and that it does not make a big difference one way or the other.

The final two layers that need closing are the rectus sheath and of course the skin. The rectus sheath is the most important layer (not surprisingly - it's fascia!) and needs to be sutured with strong material. The skin can be closed with sutures, staples or various other methods, none of which have significant advantages over the other. It is sometimes necessary, especially in subsequent cesarean births, to place a suction drain underneath
the rectus sheath. This is to prevent the collection of serum or blood in this area, which could then become a site for infection. These drains would typically stay in for 12 to 24 hours. The urinary catheter and IV are usually also removed at the same time.

With the current application of new spinal anesthetic methods, most patients are able to walk around the same day of the surgery with little pain. The long lasting effects of this spinal anesthetic provide pain relief for 18 to 24 hours with little need for further medication. Most of my patients are also able to eat a light meal and drink as much water as they like the same day.

On average most women with a cesarean birth stay in hospital for about three days and their staples or sutures are removed on day four. The hospital stay is thus, on average, certainly somewhat longer than for vaginal birth. The costs involved are also higher. These would differ tremendously between different countries so there is not much sense in discussing it here. In the U.S. costs also differ from state to state, and between different insurance companies and Health Maintenance Organizations. In Canada, with its socialist medical system there is no charge to the patient whether the delivery is vaginal or by cesarean. The higher costs of cesarean birth are borne by the specific hospital and provincial Medicare program where the delivery takes place.

The scar after cesarean birth is usually not unsightly and in fact is often difficult to see. This depends to a large degree on the patient's skin type, the presence or absence of infection in the wound and of course the location and length of the incision. The underlying skin will lose some of its pliability, which sometimes causes an overlying fat roll, if present, to curl around the scar. Although some women complain of this, it needs to be pointed out that most women who have had children have some signs of stretching of the abdominal wall, for instance stretch marks or some extra skin laxity. Be proud of it!

It is certainly true that a cesarean birth is more impersonal and certainly more " medical" than a natural vaginal birth. This cannot be changed. With newer spinal anesthetic techniques however, the "mother-to-be" can now participate in the event to some degree in that she will be able to hear exactly what is going on, including baby's first cry. The husband or significant other can also be part of the happy event and even watch the delivery itself. The baby is usually handed to the father almost immediately, if it is healthy, and can be shown to the mother.

IV. Cesarean Section

Effects of cesarean birth on the newborn:

One of the worst things that could happen during elective cesarean birth is if the baby is delivered prematurely. The most serious risk of prematurity is that of undeveloped lungs causing respiratory problems or even failure. Fortunately modern ultrasound technology makes gestational age determination very accurate and this problem should thus not be of significant concern. The ultrasound should however be done as early as possible and certainly before 22 weeks, since ultrasounds after this date cannot determine accurate gestational age.

Most women are aware of the methods of gestational age determination according to the last menstrual date. Even though this method can be quite accurate, given certain preconditions, large studies have proven that on average, ultrasound determination is more accurate and is preferable if an elective cesarean section is to be planned. The reason for this is that ovulation is sometimes delayed, with fertilization and the start of the pregnancy thus being delayed up to two weeks. If preceding menstrual cycles were not completely regular the uncertainty is compounded immensely. For these and other reasons it is thus preferable to use the ultrasound for dating. The cesarean should be planned for after the thirty eighth week of gestation, when it is almost certain that the infant's lungs and other critical organ systems have developed adequately.

Even if great care is taken to determine gestational age accurately and to perform the cesarean sections only after 38 weeks (by definition, a term pregnancy), respiratory difficulties are more common in cesarean born infants than vaginal born ones. These difficulties are almost always transient and of little consequence, but they do cause a higher percentage of cesarean born infants to spend time in an incubator. The reason is the absence of the natural squeezing vaginally born infants experience during their long passage through the vaginal birth canal. In the uterus the infant's lungs are filled with amniotic fluid which the unborn baby breathes in an out constantly from very early in the pregnancy. This breathing action and the presence of amniotic fluid is absolutely essential for normal lung development. During birth the squeezing through the birth passage causes an increased pressure inside the infant's chest. This increased pressure causes the fluid to be taken up by the blood vesels and lymphatic channels (channels similar to veins but filled with excess fluid) in the chest and lungs, thereby emptying the lung airspaces of the fluid to a large degree. Some of it might also be squeezed out through the infant's mouth. It is obvious that these processes do not occur during cesarean birth. Undeveloped lungs in the inadvertently prematurely cesarean born infant will exacerbate this problem and can lead to significant respiratory difficulties. Fortunately however, in the term cesarean born, the increased lung fluid usually leads to a very temporary condition called, appropriately, "wet lung". The most common situation is that the fluid gets reabsorbed within a few seconds to minutes after birth with no further consequences.

By far a more serious problem is a condition called "meconium aspiration". This is where an unborn infant moves its bowels inside the uterus and then inhales the meconium (unborn baby poop). Meconium is formed from sterile material, mainly cells that have sloughed from the developing fetus's immature bowel, and should not be confused with feces. Be that as it may, it is still very bad news if inhaled by any fetus since it has the potential to cause serious harm or even death. A common reason for fetuses to pass meconium while still in the uterus is stress, often during the birth process. Fetuses also often pass meconium even before labor initiates however, especially in the post-term (gestational length significantly longer that the average of 40 weeks) or growth retarded fetus. Cesarean sections could be expected, therefore, to prevent some cases of meconium aspiration since it will be done at 38 weeks and the stress of labor is eliminated. If the fetus has however already passed meconium in the uterus, for whatever reason, and if aspirated (inhaled), the risk of potentially serious meconium aspiration syndrome is elevated. The squeeze-related emptying of the infant's lungs is absent, and the presence of meconium in conjunction with "wet lung syndrome", can cause serious trouble. My own firstborn, by cesarean (not elective) at 42 weeks, spent three days in a neonatal intensive care unit with serious meconium aspiration syndrome. I thus have firsthand and traumatic experience with this problem, and although her situation was completely different to the purely elective cesarean in an otherwise normal pregnancy at 38-39 weeks, respiratory problems should never be underestimated.

During the cesarean, most obstetrician and or pediatricians (depending on the local custom) will, in a case where meconium is found, suck the infant's mouth and nose passages as soon as the baby's head is delivered through the wound. This will minimize the risk of the infant inhaling the meconium with the first breath.

Ancillary benefits of cesarean birth:

Although the following should never be used as a primary indication for cesarean birth, there are a few incidental benefits, which could be quite significant depending on the patient's particular situation.

Especially in rural areas with inadequate surgical and obstetrical backup, many patients have to travel to larger centers to await their labors and delivery. In many cases these waiting periods extend into weeks, and the final total costs escalate dramatically. With hotel bills, restaurant meals, etc., the final bill could easily cause financial hardship. The mental stress of waiting for something to happen in an unfamiliar surrounding, away from friends and family, is often not adequately appreciated by the health care providers. In many cases these patients request induction at or just after term. The health care provider then tries to find justification for this intervention which has significant drawbacks of its own, and often ends up performing an avoidable emergency cesarean section, resulting from failed induction.

In contrast, an elective cesarean birth would have meant a planned trip with a total stay of approximately 3 days in hospital. After that its back home with baby in arms.

With elective cesarean the exact birth date can be planned to some degree, and in any case it will be known beforehand so family arrangements can be made in ample time. There is little stress, and in the well prepared patient, little fear. There is no reason to spend hours in training and instruction on how to push, and no need to fear a long drawn out and painful affair.

I do not want to make too much of this however, since I do not believe that any of the things I just said, in and of themselves, are acceptable reasons to have major surgery. Against the backdrop of the rest of the information in this manuscript, however, these ancillary benefits form part of the complete picture.

Certain medical or obstetrical conditions might make the choice of an elective cesarean birth more or less beneficial. Since each case is different, these will have to be discussed individually.

V. Summary and Final Comments

Putting it all together

The pelvic floor is an incredibly important part of the human anatomy, which is crucial to health. In women, the pelvic floor has additional functions, related to reproduction, sexuality and childbirth, which are important for the well-being, womanhood, and quality of life of the individual. Unfortunately, the pelvic floor is also one of the most neglected organs, and one of the least understood parts of our anatomy. This is partly because of the inaccessibility of the structures, partly because of the difficulty in visualizing the pelvic floor, but maybe also partly as a result of the male dominance in the medical sciences until very recently. Pelvic floor prolapse and dysfunction, including incontinence, are after all almost exclusively female disorders. Fortunately research and interest in pelvic floor disorders are growing rapidly.

The politics of childbirth and special interest lobby groups have tended to focus almost entirely on the immediate problems and issues regarding childbirth. In this regard especially the "natural childbirth movement", has done a great deal in questioning many interventions that were in the past accepted as routine. This has definitely contributed to making the whole pregnancy and childbirth experience happier, with more satisfied women at the end. Unfortunately the long-term effects of short-term thinking are not adequately addressed. Late complications are no less of a problem, just because they do not occur in the labor room!

Many vocal childbirth advocates have never been overwhelmed with women with severe urinary incontinence, diminished sex lives, inhibited physical activities and the resultant severe loss of quality of life.

My aim with this book is to educate and stimulate the reader, to reevaluate the pelvic floor and its relationship to vaginal childbirth. I believe the pelvic floor needs to be considered as an integral part of prenatal education. Patients need to understand the effects of vaginal childbirth on their pelvic health, and need to be involved in the decision making process regarding the most appropriate birth for them. This decision should not be made on the basis of fear, but with the empowerment of knowledge.

I believe that since we currently have NO effective way to predict or exclude the sustaining of severe pelvic floor damage during vaginal childbirth, women should have the right to choose elective cesarean birth.

VI. References

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VII. Glossary

Most terms and concepts are explained in the document itself. Here is a short explanation of some concepts and terminology.

Altriciality: Relative underdevelopment of the human newborn infant compared to other primates. Resultant from shortened gestation.

Antepartum: The pre-delivery pregnant period.

Anterior: Top or upper.

Atrophy: Thinning and decreased blood flow to tissue resultant from a lack of hormones, most commonly estrogen.

Bipedal: Walking erect on two legs.

Bladder neck: Junction between urethra and bladder.

Cervix: The tip of the uterus. Also the intravaginal part of the uterus. This needs to open before delivery can occur. This is where Pap smears are taken from.

Classical caesarian section: Caesarian section where the incision in the uterine muscle is made through the thickest part of the uterus. This leads to future significantly increased risk for rupture of the scar.

Cystocele: Prolapse of the bladder into the vagina. This can be seen as a bulge from the anterior wall of the vagina.

Delivery: The act of giving birth.

Denervation: Loss of neuronal connections

Detrusor instability: Instability of the bladder muscle leading to uninhibited, abnormal, bladder contractions. This leads to urgency or urgency incontinence.

Devascularization: Loss of vascular connections.

Elective caesarian birth:Delivery of baby by planned caesarian section

Endopelvic fascia: The fascia of the inner pelvis.

Enterocele: A true herniation into the top of the vagina. This results from loops of small bowel herniating through a fascia tear into the space between the pelvic fascia and the vaginal wall.

Epidural anesthetic: Injection of anesthetic solution in the epidural space. This is done by placing a needle and catheter into the lower back outside the spinal column. Patients lose motor and sensory function in the lower body but remain awake. Epidurals can be "topped up" as a result of the catheter that remains as long as necessary.

Episiotomy: An incision made in the lower vulva, to increase the vaginal outlet aperture.

External sphincter: The outer layer of the sphincter. Usually under voluntary control.

Fascia: Connective tissue supporting organ structures. Consisting of mostly collagen fibers, this tissue makes up ligaments and keeps muscular bundles together as well as lending structural integrity and strength to the body.

Fecundity: Number of children.

Fetus: The intrauterine unborn infant.

Flatus: Bowel gas.

Forceps delivery: Delivery accomplished by the obstetrical forceps.

Genuine stress urinary incontinence: Incontinence related to episodes of increased intra-abdominal pressure.

Gestation: Length of pregnancy.

Gynecologist: Specialist physician specialized in female disorders, particularly those of the reproductive and urological organs.

Hematoma: Blood clot.

Incidence: New occurrences of a disorder per year.

Incontinence: Loss of normal bodily control over the storage role of a particular organ.

Incontinence: Anal/fecal incontinence: Loss of storage mechanism of rectum. This means loss of control over flatus or stool.

Incontinence: Urinary Incontinence: Loss of control over urinary storage function, thus leakage of urine.

Induction of labor: The process of initiating and expediting labor and delivery.

Informed consent: A contractual agreement between a patient and a physician, whereby the patient gives permission to undergo a certain procedure based on as clear an understanding of the issue as is possible. This understanding should be based on education and explanation.

Innervation: Connection with intact nerves. This is used in conjunction with muscles.

Internal sphincter: The internal layer of the sphincter. Usually under involuntary control.

Intra-abdominal: Inside the abdominal cavity.

Intrauterine: Inside the uterus.

Invasive: As in "invasive procedures": Procedures involving interference to change an outcome. It could also mean penetrating, or entering, the temporal order of the proceedings, or the physical body.

Laparoscopic surgery: Surgery by using a laparoscope and minimal access incisions. In this way, large skin incisions are avoided.

Late complications: Those complications occurring a significant distance in time from the causal event.

Levator ani: The main muscle of the pelvic floor made up of different parts. These parts include pubococcygeus, iliococcygeus, coccygeus, and ischeococcygeus.

Midwife: Non-physician practitioner attending and helping during labor and delivery. Midwives are often, but not always, nurses.

Morbidity: The development of complications. total non-interference by attendants. All childbirths are in some form or other, "unnatural". The term is used loosely, meaning different things by different people.

Mortality: Death

Mucosa: Epithelial tissue encountered in the mouth, vagina, anus, etc.

Natural childbirth: A great misnomer, normally used to indicate the natural order of childbirth as in the "natural" state. In reality, this would mean total non-interference by attendants. All childbirths are in some form or other, "unnatural". The term is used loosely, meaning different things by different people.

Neonatology: The specialty of looking after new born babies.

Obstetrician: A specialist medical practitioner specialized in looking after pregnant women, and the delivery of the baby.

Operative vaginal delivery: Vaginal delivery by the use of instruments, for instance, obstetrical forceps or vacuum.

Parity: Number of babies where the gestation went to term.

Pelvic floor dysfunction: Disorders of the pelvic floor related to physiological or anatomical abnormalities. They include incontinence, prolapse, pain syndromes, and others.

Pelvic floor: The floor of the abdominal cavity. It pertains to those structures that form the natural bottom of the pelvic and intra-abdominal cavities. For its constituents and anatomy, see text.

Perinatal: Viable fetus pre-birth, up to 7 days after birth.

Perineal body: The thickened part between the anal and vaginal openings.

Peritoneum: Thin shiny layer of tissue covering the inner wall of the abdominal cavity.

Pessary: A silicone device that is placed in the vagina to provide support.

Placenta accreta: Stuck placenta resultant from placental tissue growing into the uterine wall.

Placenta previa: Blocking placenta. The placenta lies over the internal cervix covering the passage the baby needs to take to be born.

Posterior: Bottom or lower.

Postpartum: After delivery. This period lasts until six weeks after delivery.

Prevalence: Occurrence of a disorder in the general population.

Prognosis: Prediction of most likely future outcome.

Prolapse: Falling out of, falling down, or dropping, bulging.

Rectocele: Prolapse of the rectum into the vagina. This can be seen as a bulge from the lower wall of the vagina.

Recto-vaginal septum: That fascial layer which separates the vagina from the rectum.

Rectus muscle: Longitudinal abdominal muscles. These are the midline muscles leading to the well recognized dimpling in well built bodybuilders.

Rectus sheath: The fascial sheath surrounding the rectus muscles.

Sacrospinous ligament: Ligament attaching the ischial spine to the sacrum.

Second stage: That stage of labor where the cervix has fully opened up.

Sphincter: Circular muscle which closes off a hollow organ during contraction.

Spinal anesthetic: The anesthetic solution is injected into the spinal canal immediately surrounding the spinal column. No catheter is used and the needle used is thus thinner. Spinals cannot be "topped up".

Spinal fluid: Fluid surrounding the spinal column and brain.

Thromboembolisis: Blood clotting and migration of clots to plug distant blood vessels.

Ureter: The muscular tubes carrying urine from kidneys to bladder.

Urethra: The tubular structure between bladder and the outside.

Urgency incontinence: Urinary incontinence related to bladder muscle contractions which occur involuntarily and in the setting of an inability to suppress those contractions.

Urinary obstruction: Inability to void.

Urodynamic assessment: Dynamic testing of the urological system whereby pressure differentials are measured.

Uterosacral ligaments: Ligaments attaching the lower part of the uterus to the sacral bone. One of the main supports of the uterus and upper vagina.

Uterus: The womb.

Vacuum extraction: Delivery accomplished by the obstetrical vacuum.

Vaginismus: Painful spasm of pelvic floor muscles on vaginal entry, such as sexual intercourse.

VBAC: Vaginal birth after previous caesarian.

Voluntary control: Conscious control.

Vulvodynia: Painful vulva, also sometimes associated with urinary symptoms, painful intercourse and generalized pelvic pain.