ChildBirth Educator Marlborough MA

The modern movement of childbirth education is enormously important in helping to educate women about labor, childbirth, breastfeeding and caring for a newborn. Doctors rarely have time to talk with their patients in any detail about the steps of labor and childbirth, and childbirth educators fill this need well.

Michelle M. Kanavos, MS, APN,BC,LCCE,FACC
(508) 875-1466
17 Wyman Ln
Marlborough, MA

Data Provided by:
Mary Grayce Zentis, RN, BSN, IBCLC, LCCE
(508) 782-6002
731 Potter Rd
Framingham, MA

Data Provided by:
Kimberly Packard
Sterling, MA
Certifications
ICEA Certified Childbirth Educator

Data Provided by:
Cheryl Aglio-Girelli, RN, BSN, LCCE, FACCE
55 Frances St
Needham, MA

Data Provided by:
Virginia M. McCabe, RN, BSN, LCCE
(617) 243-6895
29 Lee Rd
Medfield, MA

Data Provided by:
Ms. Mary A. Fischer, MSN, WHNP-BC, IBCLC,
(617) 972-5504
547 Edgell Rd
Framingham, MA

Data Provided by:
Ms. Paulette Melanson, DNP,RNC,WHNP-BC,LCCE
(508) 650-1232
7 Dean Rd
Wayland, MA

Data Provided by:
Jennifer Bronson
(978) 466-2335
Leominster, MA
Certifications
ICEA Certified Childbirth Educator

Data Provided by:
Carole Arsenault, RN, BS, LCCE
14 Longacre Rd
Needham, MA

Data Provided by:
Mrs. Michelle L Campbell, LCCE
(781) 533-9470
19 Carville Ave
Lexington, MA

Data Provided by:
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ChildBirth Educator

by William H. Parker, MD, Amy E.Rosenman, M.D. and Rachel L. Parker


CHILDBIRTH AND INCONTINENCE: THINGS YOU SHOULD KNOW

PHOEBE'S STORY
"I'm willing to do whatever it takes to fix this," said Phoebe when she came into the office about 4 years ago. This beautiful, 34 year old redhead was at the end of her rope due to incontinence. "It is strangling my life," she said. She had emigrated from England 10 years before, married a local man who worked as a hairdresser, and was now the mother of two young children. Her first child was 8½ pounds at birth, and Phoebe had a long and tiring labor ending with two and a half hours of pushing before delivering a healthy baby girl she named Cara. Following delivery, Phoebe had some mild urinary loss when she laughed or coughed, but this problem went away almost completely after about 6 months with time and the use of Kegel exercises. She was able to maintain control over her bladder most of the time, and life just went back to normal.

Phoebe's second pregnancy went smoothly, and her labor was a bit easier than with her first. The delivery was hard though, and the doctor needed to use forceps to deliver her 9- pound son, Gerald. Phoebe again experienced urinary loss after Gerald's birth but assumed it would go away as it had done with her first child. When we saw her, Gerald was two years old, and Phoebe's urinary loss had gotten worse. She had already given up aerobics classes, and she leaked with nearly every cough, sneeze or laugh.

Phoebe was a waitress in a pub that catered to British ex-patriots in our area, and she was seriously thinking about quitting her job. She was on her feet from mid-day until late evening and in order to get through the day needed to change a large pad every few hours. Since many of the customers knew her well, she often took a lot of ribbing over her red hair and having married a Yank. The atmosphere was friendly, boisterous and often funny.

The last straw with her incontinence came about because of the funny part. One evening as she was bringing a tray of drinks to a table, she overheard Ian, a frequent customer who was a hangdog, broke, and out of work store clerk, tell a pretty newcomer to the bar that he was a pilot for British Airways flying out the next day to the Bahamas. Phoebe made it past Ian and burst into laughter when she got back to the bar. But, the laugh was costly; her fortunately dark colored pants were now good and wet, and her shift was not over for an hour. Phoebe called our office the next day.

When we took her medical history, the difficult labor with her first child and difficult delivery with the second stood out as warning signs of possible damage to her urinary system. Our examination showed there was a weakness of the pelvic muscles supporting the bladder. We thought further testing was needed to be sure that no other bladder problems existed, and so urodynamic testing was performed. The results of the examination and urodynamics showed that the problem was primarily weakness of her pelvic muscles and ligaments that were allowing the bladder to come out of position when Phoebe laughed, coughed, sneezed or exerted herself by lifting heavy trays at the pub. Called stress incontinence, this is the most common type of incontinence following childbirth. Phoebe asked what had caused her problem. We answered that although there are a number of things that can lead to damage to the pelvic muscles and nerves, the most common is childbirth. Fortunately, there are a number of good treatments available to fix Phoebe's incontinence.

DOES CHILDBIRTH CAUSE INCONTINENCE?
Everyone who has had a child knows that once a baby is born, life is never the same again. Women also know that their bodies are never exactly the way they were before they gave birth. Recent evidence tells of just how different a woman's body may become after labor and delivery. Women who have not delivered a child vaginally rarely develop incontinence or pelvic muscle relaxation, while women who have vaginal deliveries sometimes do. Again, be assured that most women will not go on to develop incontinence after childbirth.

This chapter is to help you understand what we know about why some women who delivered babies have problems with incontinence, but it may also cause you concern about those women yet to deliver or yet to even conceive. Will their ability to stay dry when they get older be compromised by childbirth? What should they do? What should they be told? Understand that we are still at an early stage of fact-finding for this new information, but this chapter will consider the answers to these questions.

There are many factors that can lead to incontinence - the strength of the pelvic supporting structures that you were born with; the forces these structures have resisted over the years, including childbirth, heavy lifting, and straining during bowel movements; your ability to heal if these tissues are injured; the effect of the ageing process on the collagen that gives strength to these structures. Probably no one factor is completely responsible for the development of incontinence. Further research is needed to help clarify the importance of each possible cause and the interplay between them. This research will likely benefit those women who are yet to have children.

We do know the connection between incontinence and childbirth has been implied for a long time. When gynecologists see women for problems of incontinence, they are not surprised to find the most severe problems often in those women who had many children or who delivered large babies. Recently doctors started working out the details of these relationships and are looking for the specific reasons why some women go on to develop incontinence and other women never have this problem. Although the studies are preliminary and involve only small numbers of women, some details are starting to emerge.

About 10-20% of women who have a vaginal delivery will be bothered by prolapse, bulging of the bladder, rectum or uterus into the vagina, by the time they reach 50 years old. Women who deliver one child have a 3 times greater risk of developing prolapse than women who have not had children. Women who delivered two children have a 5 times increased risk, and women with four or more children have an 11 times greater likelihood of developing this problem. Women who need to push the baby out longer than one hour or who deliver larger babies appear to be at a greater risk of developing incontinence later in their lives. There is increasing evidence that childbirth is responsible for much of the injury to the muscles and nerves of the pelvis. This injury eventually leads to urinary loss and pelvic prolapse. Most women are not aware of this somewhat new information. In fact, many doctors are not apprised of the recently collected data. This chapter explains what we know, so far, about incontinence and childbirth.

DOES A LONG LABOR LEAD TO INCONTINENCE?
The modern movement of childbirth education is enormously important in helping to educate women about labor, childbirth, breastfeeding and caring for a newborn. Doctors rarely have time to talk with their patients in any detail about the steps of labor and childbirth, and childbirth educators fill this need well. Many childbirth educators also focus on avoiding medical interventions that interfere with a "natural" birth, especially cesarean section. Lamaze, the Bradley method, and many midwives and doctors encourage women to labor as long as needed and as long as the baby's health, as monitored by the heartbeat, can tolerate labor. As a result, prolonged labor or prolonged pushing is sometimes encouraged in order to avoid a cesarean section. However, while safe for the baby, it appears that these concepts may not be in the best long-term interest of the mother. We know now that prolonged and difficult labors may lead to permanent nerve damage and weakening of the pelvic muscles and the supporting structures to the uterus, bladder and rectum. This can eventually lead to dropping of the pelvic organs or incontinence.

As every woman who delivers a child knows, labor and delivery subject the body to forces that are not encountered in any other circumstance. Muscles and nerves in the pelvis are especially affected. As the baby's head comes down into the pelvis, it presses against the muscles that line the inside of the pelvis. The farther down the baby's head goes into the pelvis, the greater the pressure against these muscles and underlying nerves. After the cervix is totally dilated, the pushing phase of labor begins. The mother is usually asked to wait for a contraction to start, then hold her breath, and bear down as hard as she can in order to push the baby out. This bearing down presses the baby's head against the mother's muscles and nerves to such an extent that the normal flow of blood is cut off temporarily until that push is over. Without a fresh supply of blood, the tissues are deprived of oxygen and nutrition, making them more susceptible to damage. The pressures generated by pushing are 3 times higher than the tissues would normally tolerate for any prolonged time. However, the few minutes of rest in between contractions usually lets blood flow back to the area. This fresh blood carries oxygen and nutrition to the muscles and nerves and carries carbon dioxide and waste away. The few minutes between contractions are normally enough for the tissue to recover.

However, unless delivery occurs quickly, the baby's head continues to be pressed against the tissues. For some women this pressure can cumulatively add up to many hours. Two nerves, called the pudendal and the pelvic nerves, lie on each side of the birth canal within the muscles that are directly under the baby's head. Because they are so close to the baby's head, these nerves are especially vulnerable to the pressures of labor. The pudendal and pelvic nerves carry the signals from the brain to the muscles that hold the bladder and rectum in place. If these nerves are injured, the signals meant for the muscles around the bladder, vagina, and rectum may not be transmitted properly. Without stimulation from the nerves, the pelvic muscles, like any underused muscle in the body, can become weak and flaccid. Some studies show changes in the function of these nerves in more than half of women following vaginal delivery. Interestingly, a prolonged labor or pushing phase before a cesarean is performed makes it likely nerve damage has already happened even if the baby is eventually delivered by cesarean. Over time and with age, the normal supporting tissues of the bladder, rectum and uterus weaken, adding to the effect of childbirth injury. The result can be incontinence of urine or stool, or prolapse.

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