A lot of patients who come to see Dr Jocelyn Fitzgerald – an assistant professor of obstetrics, gynecology and reproductive services at the University of Pittsburgh in the division of urogynecology and reconstructive pelvic surgery – didn’t know that her specialty even existed.
“I like to joke, but actually I’m very serious, that the reason more women don’t know about urogynecology is because we would have to admit that we need urogynecologists,” Fitzgerald says.
Urogynecologists specialize in disorders of the pelvic floor and all of the organs contained within the pelvis of people assigned female at birth: the vagina, the uterus, the bladder, the rectum and all of the pelvic muscles and nerves. One of the most common conditions they treat is vaginal prolapse, which usually happens as a result of childbirth, and occasionally requires reconstructive surgery.
Fitzgerald says it makes her “angry” that so many people are blindsided by the pelvic floor injuries and complications that can happen during and after childbirth. “We portray motherhood as this beautiful calling, and for some women it is,” Fitzgerald says. “But that doesn’t change the fact that the calling comes with some real costs.”
We talked to Fitzgerald about some of the underdiscussed physical ramifications of childbirth, and how patients can get the information and care they need.
This interview has been edited and condensed for clarity.
In January, you posted on X: “As a urogynecologist, I cannot emphasize more strongly, literally am begging women to learn about what actually happens and can happen to your body during childbirth before getting pregnant. Don’t be blindsided. Go in prepared, ready, and certain in your choice to be a mother.” What prompted you to post that?
I think it’s so important for women to approach their reproductive life strategically. What I focus on is the physical ramifications. People think of the postpartum period as the six weeks after you deliver, but really postpartum is the rest of your life once you’ve had a delivery.
The reality of childbirth and how it is portrayed are so wildly different that I can’t help but feel frustrated on behalf of my patients. They’ve been fed this romanticized vision of birth and motherhood. As a result, they think they are the only ones to have a birth injury, and they hide it for as long as they can. By the time they come to see me, they are really scared. For example, if they have [pelvic] prolapse, a lot of times they think they have cancer or something unfixable or they’ve never heard of prolapse. They’re blindsided, which makes me really angry for them because it’s so common. It happens to 50% of women in their lifetime, and yet it’s so taboo that they’ve never heard about it.
We have this idea that birth is no big deal, everyone does it and it’s a natural thing your body was made to do. When it goes “wrong”, so to speak, women think they’re the only one and they don’t want to give the impression that their body couldn’t do it.
If patients came to see me sooner, I could intervene sooner and they would have a better outcome. The sooner you treat incontinence, the sooner you treat prolapse, the better chance you have of it getting better. These patients would get years of their life back where they didn’t have to be suffering.
What are some of the things that happen during and after childbirth that most surprise your patients?
Incontinence is one of them. [Postpartum incontinence happens to roughly 30% of women.] Pain is probably the next biggest one. People are really surprised by all these painful things they’ve never heard of, like pubic symphysis pain (pain in the joint between the left and right pelvic bones) or the way that their sacroiliac joints (the joints that link the pelvis and lower back) change and their back posture changes.
They’re also very surprised by how much intercourse can hurt after they deliver. Anywhere from 25 to 50% of women experience this after giving birth. A lot of times that has to do with a birth injury, but sometimes it’s muscular spasms because the muscles, in trying to protect themselves from the injury they’ve just undergone, have overcontracted. In that case, you need to go to physical therapy.
The pelvic floor is a miracle. There is no other biological process quite like birth, in terms of how these organs can stretch so far and then go back to normal, or mostly normal. Imagine any other muscle in your body that is stretched to 10 times its natural length, and then it has to snap back into place. Of course that muscle will hurt – it can go into spasm, it can become not very functional. If you over-rotated or overstretched your shoulder, you would go to physical therapy so you can get the coordination of that muscle back. The same is true of your vagina and pelvic floor.
What are some of the most common birth injuries?
The most common one people think of is tearing. Usually that’s a tear that involves the perineum, the area between the vagina and the rectum. There are grades of tears. A second-degree tear goes into the perineum, a third-degree tear goes into the external anal sphincter, and a fourth-degree tear, which is the worst kind, goes into the internal anal sphincter. The most common is a second-degree tear. Third- and fourth-degree tears are relatively rare, but still happen to 5-8% of women.
Patients tend to know about tears the most, because we repair those at the time of delivery. But there are other birth injuries that are not as obvious at the time of delivery. There’s something called a levator avulsion, for example. The muscles of the pelvic floor that go into spasm the most are called the levator ani muscles, and they are attached to the inner surface of the pubic bone. With a levator avulsion, they can tear off the pubic bone. You can’t really fix that at the time, and it’s not an injury that bleeds. That is a very big risk factor for developing prolapse down the line.
And there’s other things that can be injured, but more rarely, like a urethral tear. I’ve seen clitoral tears, labial tears, deep side-wall tears in the vagina that go up into the uterus.
I’m a woman in my 30s, and I’ve had a lot of conversations with friends about whether we want kids. A lot of the calculus seems to be: what would my life look like? How would I afford it? How would it affect my career? How would my partner and I divide the work of parenting? Much more rarely do we discuss the act of childbirth itself, and the long-term physical impacts of that.
Your body is really different after. Sometimes it’s not that much, and a lot of the time you heal. The female body is amazing, and a lot of women do really well. But I would challenge you to find any woman who tells you that after birth, things feel or function the same way. They just don’t. It’s a fantasy to think that you’re going to shove a person out of a tiny hole – and through a container of muscle that has your bladder, bowel, uterus, vagina and all the muscles and nerves that run down your legs and connect your pubic bone and back – and nothing is going to be different.
A lot of people get mad at me online and say that I’m fearmongering and trying to convince women not to have babies. That is not the case. If the idea that you might leak urine after having a baby is enough to make you not want to be a parent, then you probably don’t want to be a parent in the first place and I’ve done you a favor. For people who really want kids and are committed to parenthood, that information won’t deter them. It will be a gift, because when you can treat your pelvic floor disorders, you can be a better mom – you can run and play with your kids and not sideline yourself because you worry you’re going to have an accident.
When you tell the truth, women know that they are not alone. It makes them really think about what they want for their body, what they want for their motherhood journey, and how to find help if they need it. In fact, there is research that shows women who go into birth educated about pelvic floor disorders actually have less anxiety about the process, not more.
How can women prepare themselves for some of these potential injuries and complications?
There are definitely more resources than there used to be. Just knowing that urogynecology is a specialty in medicine that is dedicated to these issues is a huge part of the battle. It’s rare, but I’ve had patients come to me before they get pregnant to ask for counseling about pelvic floor disorders related to birth. I’m not saying everyone needs to do that.
There are a lot of patient-facing resources on the American Urogynecology Society (AUGS) website. [Fitzgerald is a member of AUGS.] There’s an inexpensive AUGS book – I don’t make any money from it – that is all about pregnancy and postpartum and your pelvic floor. It’s really easy to read, and has information about how to hold your baby so that you protect your back, and other postural and hormonal changes that happen.
And just know that pelvic floor therapy is out there. There are a lot of reputable pelvic floor therapists that have a lot of good information about pelvic floor rehabilitation. And talk to your obstetrician, of course.
