By Andrea Hall

Andrea Hall is an editor, NVA Executive Board member, and the mother of two young boys. She has done extensive research on pregnancy and childbirth.

Most pregnant women with vulvodynia are brimming with questions about the possible effect of labor and childbirth on vulvar pain. This article covers aspects of labor and childbirth that may be especially challenging for women with vulvodynia and encourages discussion of these issues beforehand with an obstetrician or midwife. For our purposes, we will use the word doctor in referring to a pregnant woman's health care provider, but we recognize that some women may prefer to use a midwife.

Childbirth Options

In consultation with her doctor, a pregnant woman who suffers from vulvodynia can choose either a vaginal delivery or a Caesarean birth, also known as a C-section. “Should I have a C-section?” is typically the first question a pregnant woman with vulvodynia asks her doctor. In most cases, surprisingly, the answer is, “Having vulvodynia is not, in itself, a reason to choose a Cesarean section.” Many women assume that vulvodynia sufferers should do everything possible to avoid trauma to the vulvar area, but a vaginal birth does not automatically lead to exacerbation of symptoms, or if a woman is pain-free, to the return of symptoms. There is no research outcome data on women with vulvodynia who have had vaginal births, but some experts say it is unusual for a permanent increase in vulvar pain to occur. It is even possible that having a vaginal birth may decrease future pain with sex, because the stretching of the introital skin during delivery can help reduce the discomfort of superficial friction when sexual intercourse is resumed.

Cesarean Birth

A C-section is major surgery in which the newborn is delivered through an incision in the mother's abdomen. Compared to other major surgeries, C-sections are very safe, but there are also potential risks, including an increased risk of infection in the uterus, pelvic organs or abdominal incision; blood loss; blood clots; and injury to the bowel or bladder. Women who deliver by C-section face a longer hospitalization period and recovery time, while simultaneously dealing with the universal challenges of the postpartum period. In addition, dryness and atrophy of the vagina due to estrogen suppression during breastfeeding is more likely to be problematic for women who deliver by C-section. A vaginal delivery leads to stretching of the vaginal walls, which helps to counterbalance the typical tightening of the vagina that occurs during breastfeeding. This tightening may make tender, fragile vaginal tissue even more uncomfortable and add to the discomfort already experienced by women with vulvodynia.

On the other hand, when C-sections are required, they can save lives. Situations in which a Cesarean section may be necessary include, but are not limited to, a breech presentation (buttocks-or feet-down), placental abruption (the placenta tears away from the wall of the uterus), or a pinched or compressed umbilical cord. In these cases, the benefits of Cesarean delivery far outweigh the potential risks, compared to a vaginal delivery. Note that none of these precipitating causes have any relationship to vulvodynia.

During a C-section, the surgeon makes a horizontal incision in the abdomen and uterus, usually just above the pubic hairline. The newborn is then lifted out through this incision. Prior to the actual surgery, there are a number of steps taken to ensure the safety of the procedure. After the pubic hair is shaved, the abdomen is cleaned with an antiseptic solution, and a catheter is inserted to empty the bladder. Next, an I.V. is inserted into the arm or hand to administer any necessary fluids and medication throughout the procedure. The doctor uses either general anesthesia or a local anesthetic which numbs the lower half of the body, allowing a woman to remain alert throughout the C-section. Surgical drapes arranged just above the incision site block a woman's view of the procedure. If a partner or other family member/friend wants to be present during the delivery, he/she will be suited up in a sterile medical gown and may watch the surgery.

Most of the topics discussed below are pertinent to women who intend to have a vaginal delivery, but it should be noted that some women plan a vaginal birth and eventually need a C-section at some point during labor.

Medicated vs. Unmedicated Labor

The first major issue facing a woman who intends to have a vaginal delivery is whether to rely on anesthesia or proceed with unmedicated labor. The decision whether or not to use anesthesia should be the choice of the pregnant woman, since no one knows her tolerance for pain better than she does. Before a decision is made, she should educate herself about the pros and cons of each option and how those factors might affect her. It is perfectly normal for a woman to be anxious about the pain of childbirth and it is highly recommended that options be discussed with the doctor. Once a decision is made, however, the matter should not be considered completely closed. During pregnancy, labor and delivery, it is best to keep an open mind about pain medication as well as other procedures. There is no way to anticipate how difficult or how long a woman's labor will be, or how fatigued she will become.

For women with vulvodynia, there are two schools of thought on pain relief during both labor and delivery. The first approach is to ensure that she be as “numb” as possible in the vulvar area to avoid any additional discomfort during labor and delivery. If a woman can't tolerate vaginal exams because of pain, she will likely want to eliminate the pain of exams during labor. One way to accomplish this is to use a regional anesthetic, such as an epidural. The other option is to reduce the number of, or entirely eliminate, vaginal exams.

The alternative viewpoint is that anesthesia can stall labor, and when labor progresses too slowly, it's more likely that the doctor will need to intervene with forceps or vacuum extraction. These interventions may cause trauma to the perineum (muscle and tissue between the vagina and rectum). There is also concern that an epidural or other type of regional anesthesia will make the muscles beneath the perineum flaccid or limp, increasing the chance that an episiotomy may be necessary. (See Intact Delivery and Perineal Trauma below.)

Some women, particularly those struggling with vulvar pain on a constant basis, may simply not want to experience any more pain or discomfort than is absolutely necessary. For these women, an epidural or other pain relief during labor and delivery is generally the best choice.

Labor and Childbirth

Shortly after a woman in labor arrives at the hos-pital or birthing center, the doctor or nurse will want to perform a vaginal exam to determine how much the cervix has dilated, as well as the presentation and position of the baby. This exam will be repeated just before the pushing phase of labor. Some proponents of intervention-free childbirth assert that these exams are unnecessary and may even increase the risk of infection. Women with vulvodynia who cannot tolerate pelvic exams should talk to their doctor about the possibility of reducing or eliminating the exams during labor and delivery. If they cannot be eliminated, a regional anesthetic can be given during labor to lessen discomfort.

Once the cervix has completely dilated, it's time to push. The first few urges to push may take a woman by surprise, prompting her to tense her pelvic floor muscles, which is likely to cause pain. It is best to keep the pelvic floor muscles relaxed as the urge to push begins. At this point, light breathing or panting, and relaxing the perineum are helpful.

Slowing the process of pushing the baby out gives the perineum more time to stretch, decreasing the chance of perineal trauma or laceration. Prolonged forceful pushing should be reserved for times when the baby is in distress and interventions are being considered. Some women, including those not suffering from vulvodynia, experience a tingling, stretching, burning or stinging sensation at the vaginal opening as the baby's head crowns. Some women refer to it as a “ring of fire.” The pain can be very intense and result in an overwhelming urge to push the baby out quickly, but it is still best to ease the baby out gently, if at all possible. Pushing slowly through contractions when the newborn's head crowns makes it less likely that an episiotomy will be necessary. Some birth attendants massage the perineum at this stage to assist gradual stretching, or maintain steady pressure on the newborn's head to keep him/her from coming out too rapidly. Some doctors will perform an episiotomy at this point. The pressure of the baby's head naturally numbs the perineum because it restricts blood flow to the area and this will decrease or stop the burning. Lying on one's side or remaining up- right is preferable because it will decrease pressure on the perineum and allow for maximum stretching.

Fetal Monitoring

Fetal monitors assess the health status of the fetus during labor by measuring the response of its heartbeat to the mother's contractions. Women delivering babies in a hospital may be monitored at regular intervals, e.g., once an hour for 15 minutes. Most often it is done using an external fetal monitor, which is a wide belt with two instruments attached; an ultrasound transducer measures the fetal heartbeat and a pressure-sensitive gauge measures the intensity and duration of contractions. These instruments are connected to a monitor that delivers a printout reading.

If there is a reason to suspect fetal distress, the doctor may connect the mother to an internal monitor, which requires attaching an electrode to the baby's scalp to measure its heartbeat. Because there are some slight risks, such as infection, or rash or abscess on the baby's head, internal monitoring is used infrequently, only when the benefits outweigh the risks. The use of an internal monitor requires access to the uterus via the vagina and cervix and the procedure may be uncomfortable, or even painful, for a woman with vulvodynia who has not received an epidural or other regional anesthetic.

Intact Delivery and Perineal Trauma

Whether an episiotomy or laceration will occur during delivery is a common source of anxiety for women with vulvodynia as they approach their due date. Pregnant women should feel free to talk to their health care providers about this issue.There are three possible scenarios involving the peri-neum during a vaginal birth: intact perineum, spontaneous tearing and episiotomy. Tearing is described in terms of degrees: a tear of the superficial tissues without injury to the surrounding muscle (1 st degree) a rupture of the perineal skin (2 nd degree), vaginal and rectal mucosa (3 rd degree) and anal sphincter (4 th degree). Episiotomy is a surgical incision of the perineum performed to enlarge the vaginal outlet as the newborn is crowning. It also is described in terms of degrees: the incision can be through the skin layer only (1 st degree), skin and muscle (2 nd degree), skin, muscle and rectal sphincter (3 rd degree) or involve the skin, muscle, rectal sphincter and anal wall (4 th degree). Second-degree episiotomy is the most common episiotomy and 4 th degree is the least common. In addition, there are two primary types of episiotomies: median and mediolateral. Most doctors prefer the mediolateral, which slants away from the rectum. A median incision is made in a straight line toward the rectum, but is used less frequently because it poses a greater risk of extending completely to the rectum.

Clearly the ideal scenario, for women with or without vulvodynia, is to leave the delivery room with an intact perineum. There is no research data specifically for women with vulvodynia, but studies of women in general have shown that postpartum pain is lowest among those who give birth with an intact perineum. Unfortunately, intact delivery with vaginal birth is not always possible.

As mentioned above, during the pushing phase of labor, the doctor will either attempt to stretch the perineum using perineal massage or perform a routine episiotomy (as opposed to a selective episiotomy). Women usually describe the sensation of being stretched as “uncomfortable” rather than painful. Perineal massage does not, however, guarantee intact delivery. It can take 15 minutes or more of massaging before the tissues will stretch and often the perineum doesn't stretch enough before the baby is born. Sometimes, even though it appears as if the tissues have stretched enough, an unpredictable position of the fetus, such as an elbow sticking out, can cause a spontaneous tear. Studies have found that approximately 50 percent of women who do not have an episiotomy will spontaneously tear and 50 percent will not.

Previously, it was standard practice for doctors to perform a routine episiotomy, because they thought it reduced the risk of significant tearing, pain, urinary and fecal incontinence, and pelvic floor defects. In 2005, however, a review of the medical literature found that the benefits traditionally attributed to episiotomy were non-existent and that the procedure actually increased the risk of severe tearing, pain with intercourse, incontinence and other pelvic problems after delivery. Research also has shown that when episiotomies are performed, the incisions are almost always larger than the tearing incurred without an episiotomy. Today, many doctors do not perform routine episiotomies, but they may still choose to do a selective episiotomy if the monitor indicates fetal distress. In these situations, time is of the essence and a selective episiotomy can hasten the birth.

There is no research data on how episiotomies or tearing specifically affect women with vulvodynia. While some doctors think that any new scar can be a focus of tenderness, others contend that there is no reason to think that either an episiotomy or spontaneous tear will increase vulvar pain after childbirth. Women should talk to their doctor before labor about the likelihood of having an intact delivery and can express a preference for massage over episiotomy, assuming time allows.

Forceps and Vacuum Extraction

Forceps or vacuum extraction is used in about 10 percent of vaginal deliveries. These interventions are used to speed up delivery when the baby is in distress, or to turn the baby when its position makes delivery more difficult. These procedures also may be used when either pushing has not lead to progress in the baby's descent, or a long period of pushing has left the mother exhausted.

To perform a forceps extraction, two spoonlike instruments are inserted into the vagina and applied to each side of the baby's head. The doctor turns and/or pulls on the handles to help the baby out of the birth canal. This procedure requires that an episiotomy be performed first and that regional anesthesia be administered. The risk involved is that forceps delivery can tear the vagina or cervix. Research has found that delivery with forceps is associated with a 10-fold increased risk of perineal injury compared to deliveries without the use of instruments. If the baby is in distress and a forceps delivery is being considered, vacuum extraction can be requested instead, but the final decision whether to use forceps or vacuum extraction rests with the doctor, who is ultimately the best judge of which procedure is safest.

In a vacuum extraction, a caplike device is applied to the head of the baby and a rubber tube extends from the cap to a vacuum pump that creates suction on the head. This procedure may require an episiotomy. Although vacuum extraction also can tear the vagina or cervix, it is less likely to do so than forceps extraction.

The First Few Hours After Childbirth

After the newborn arrives, the new mom must pass the placenta, which usually takes between 10 and 30 minutes. Massaging the uterus and/or nursing the newborn at this time can sometimes help speed up the process. Once the birth is complete, the pelvic area is cleaned by pouring water over it and the doctor checks to see if there are any tears that need to be repaired. If stitches are needed and the delivery was unmedicated, a local anesthetic can be given to numb the pain.

Once any repairs are complete, a nurse leads the mother to the bathroom, measuring cup in hand, and instructs her to urinate. If urination does not occur, the nurse may want to insert a urinary catheter. Women with vulvodynia may find the catheter extremely uncomfortable if they have not received a regional anesthetic or the effect of the medication has worn off. It might be possible to avoid the catheter by explaining vulvodynia to the nurse, claiming dehydration and then drinking lots of water (and turning on the tap water) to encourage urination. The nurse will provide a peri bottle (a plastic, squeezable bottle of water with holes in the top), which is used to wash, rather than wipe the vulva after urinating. A stool softener, such as Colace, can be requested to ease bowel movements, which helps reduce straining the already tender perineum.

After urinating, the mother returns to her bed and the nurse provides the first of many disposable ice packs. These cooling packs are applied to the perineum and vulva, on and off, for two to three days. After this initial period, a regimen of warm sitz baths begins. The hospital may provide a sitz bath that fits over a toilet seat or one can be purchased at a medical supply store; alternately, a clean bathtub filled with lukewarm water works fine. Sitz baths can be continued as long as they're helpful. The nurse also may provide a numbing spray, such as Americaine (available at drugstores), which helps numb the perineum if there are stitches.

After vaginal delivery, some swelling, soreness and/or bruising in the vulvar area is common. The nurse will offer Tylenol, Motrin or a mild narcotic to ease this pain. Most hospitals use self-administered medication programs that allow the new mom to control her intake of medication. Finally, even women who didn't suffer from hemorrhoids prior to or during pregnancy, may develop hemorrhoids as a result of pushing out the newborn. These varicose veins in the rectum can be painful and some women compare the burning and itching of hemorrhoids with the pain of vulvodynia. Using Tuck's medicated pads (which can be stored in the freezer if desired), along with a prescription cream or over-the-counter ointment such as Anusol, should help heal them quickly.

The new mom should expect to feel very tired after childbirth. Once she's had the opportunity to start breast-or-bottle feeding her newborn, she should try to get some rest. The newborn will fall asleep after a few hours and it's a good idea for the mom to sleep at the same time. As she begins this new phase in her life, the body begins its healing process and eventually returns to its pre-pregnant state. She should continue to eat healthy foods, drink plenty of water and rest as often as possible—it won't be very long before she has to keep up with her increasingly mobile infant!