Looking back, knowing what I know now, I can see I was an obvious candidate for pelvic organ prolapse. I had most of the suspected risk factors: I was thirty-six when I became pregnant for the first time, not exactly in the first flush of youth anymore. I'm pale-skinned, flexible-jointed, and prone to coughing due to recurrent bronchitis. My uterus has always been retroverted (tilted backward). My baby had a huge head (still does!) and this had been clearly established with ultrasound exams at several points during my pregnancy. And perhaps most significantly, my mother and grandmother before me both had prolapses. My mom had a cystocele, and her mother must have had severe uterine prolapse - not that Grandma talked about it, but my mom recalls her wearing a sort of harness to hold everything in.

I went through my pregnancy and delivery in Berlin, Germany. But I don't think my being in Germany made a difference to the outcome of my story. Apart from frequent ultrasounds and much less concern about Group B strep infection, German obstetricians adhere to routines fairly similar to those in the US. The cesarean section rate was never as high in Germany as in the US, with German doctors more readily resorting to vacuum extraction. But as US doctors have come under pressure to contain costs, they too are making much more frequent use of forceps and especially vacuum extractors.

One of the things that deeply angers me is that we make over a dozen prenatal visits to the doctor, yet obstetricians make no effort to assess one's risk for prolapse. Like most expectant moms, I was checked for gestational diabetes, preeclampsia, HIV, toxoplasmosis, Rh incompatibility, and a host of other complications. These are all routine tests, and while they all cost time and money, they are well worth it because they protect the health of mother and baby. Would it be too much trouble to simply ask a few questions on the risk factors for prolapse during a prenatal visit? That information, available to the obstetrician who attends the delivery, would provide a basis for weighing the relative risks of various interventions.

If all my risks had been clearly reflected in my record, a responsible obstetrician would have thought twice before giving me a big episiotomy (mediolateral), pulling out my baby with a mid-pelvis vacuum extraction, and applying fundal pressure to the top of my uterus - interventions known to increase the risk of prolapse. But no one - least of all myself - was aware that I faced a much greater than average risk. Here is how it played out:

My labor had started fast and furiously. Even though I demanded and got an epidural (which often slows labor), I was fully dilated at ten centimeters after just five hours. And that is where I stayed for the next seven hours. My baby failed to make the first rotation that would have allowed him to enter the birth canal. He got stuck basically at "zero station." Given that I never felt any urge to push, he may not have even come that far.

To their credit, my doctors and midwives tried the full array of techniques for getting my baby to turn and move on down: acupuncture, homeopathic drugs, various labor positions, repeated catheterization (to make sure the bladder stayed out of the way), and enough Pitocin to deliver a baby elephant. Finally, out came the vacuum extractor and the threat of a cesarean section if the vacuum didn't do the trick promptly. While one doctor pulled, another applied fundal pressure, and I pushed as hard as I could given that I was completely numbed in anticipation of the possible c-section. When my son was born in three contractions, I sobbed with relief that he was OUT and safe, and that I'd been able to avoid going under the knife. He weighed eight pounds, six ounces. As predicted, he had a big head. I thought I'd gotten awfully lucky.

Little did I know how tough and ultimately incomplete my recovery would be. I lost a lot of blood (probably more than the half liter the doctors estimated, given that I was very weak for about two months after the birth - I suspect that they often round down their blood loss estimates in order to avoid the question of a transfusion). Eventually my strength began to ebb back, but by then I had noticed a far more troubling problem. About two weeks after my son's birth, I felt a strong sensation of burning and pressure in my bladder. I wondered if it might be a bladder infection. But it didn't feel like a typical infection: I didn't have a burning sensation upon urination, and my discomfort got worse toward evening. As all my friends and my midwife said it was "normal" not to feel "right" so soon after childbirth, I waited a couple more weeks before going to the doctor.

When I finally did see a doctor (my regular primary care physician), I heard that I did indeed have a bladder infection. I can hardly express how happy I was to hear that news! I wasn't thrilled about taking antibiotics while breastfeeding. But, since I'd started to suspect pelvic organ prolapse, I was relieved that I seemed to have a treatable problem that I could expect to disappear soon.

The only catch was - as you've guessed by now - I didn't get to feeling any better. A repeat urine check confirmed that the infection had cleared up. And a pelvic exam confirmed my worst suspicion: moderate descent of the uterus and of the vaginal walls, as well.

Unlike most women who discover this problem at a young age, I knew a little about pelvic organ prolapse. Not enough, but something. In my work as a medical historian, I have researched the reproductive lives of women in the past, so I knew that prolapse used to be regarded as a major health issue, and not only for elderly women. Fear of prolapse is a paramount reason why reason women in the early twentieth century used to spend a week, ten days, or even longer on strict postpartum bedrest. There was no getting up even to use the bathroom, and the most rigorous regimes kept women flat on their backs for the first forty-eight hours or so, with a heavy sandbag on the abdomen, which was intended to help the uterus return to its proper size and position. Later, the routine use of episiotomy was justified as promising to prevent prolapse. (Scholars know now that these studies were thoroughly flawed, but many practicing obstetricians still use episiotomy almost universally.)

I had to learn the hard way, though, that prolapse is by no means a problem of the past. My gynecologist - whom I had respected highly in the past - was no help at all. When I asked about restrictions on lifting and exercise, she said there were none. So wrong! She told me to do a lot of Kegels if I didn't want my problem to become a chronic one. I know now that such advice amounts to blaming the victim. Kegels can help greatly with simple stress incontinence (which wasn't my problem) but are unlikely to help move all the prolapsed organs back into their proper places.

That's when I turned to the Internet and began my own research. When I first came across the CUPS site, I was amazed at all that could go wrong with the pelvic anatomy. Only slowly did it become obvious to me that I, too, had both a rectocele and a cystocele. Thanks to the information I found, I learned that lifting my heavy baby (nineteen pounds by four months) was indeed contributing to the problem. I got savvy about using lots of fluids and fiber to keep my digestion moving briskly. And I realized I needed to see a urogynecologist.

My gynecologist was relatively cooperative about referring me; in fact, I think she felt some relief to pass my problems off on a colleague. The urogynecologist (still in Berlin) did not examine me standing, but based on my "body feelings" I think his diagnosis was pretty accurate: moderate uterine prolapse and cystocele, and severe rectocele.

He referred me to an excellent physiotherapist, where I learned how to minimize damage when lifting my baby. She also taught me variations on Kegels and some abdominal exercises that will not harm the pelvic floor. This was the first time I felt that my problem was being taken seriously. I do feel that the physiotherapy strengthened the muscles in my pelvic floor. By the time I completed it, I was about eight months postpartum. Around that time I also began slowly weaning my baby. Since then, I do think my uterus is riding higher, so I can't say whether it was the exercises or the hormonal changes of weaning - or maybe both - that contributed to an improvement.

I was less thrilled about the urogyn's recommendation for eventual surgery. He felt it would be enough to fix the rectocele and leave the cystocele and uterus alone. Well, to his credit he wasn't keen on hysterectomy. However, I'd read by then that most urogyns advocate fixing all the prolapses at once. Otherwise, the unrepaired area is liable to prolapse further into the space "vacated" by the repaired prolapse. I think my urogyn was too fixated on sexual functioning (hence his proposal to just "tighten things up") and not enough concerned that my overall function as a human being was greatly impaired.

Soon after I finished my physiotherapy, I also demanded a pessary. (My gynecologist's classic response: "But they're for old ladies!") Luckily my urogynecologist had the full range of models and sizes. I now wear a cube that has helped considerably. The relief is not 100 percent, but my quality of life has vastly improved. I still have pain, especially in the perineal area, if I stand for too long. (Washing dishes, for some reason, is now a literal pain in the you-know-where!)

The personal issues facing me at this point are three: the emotional fallout of prolapse, the question of having another baby, and when and where I will pursue a surgical solution.

I think prolapse is a emotionally devastating at any age, but it is even more complicated the younger one is. It has posed a big challenge to my marriage. So far we are hanging in there, thanks to my husband trying hard to understand why I feel so unsexy, suffer daily pain, and don't feel able to be physically active. Linked to the crimp in my sex life is the overall damage to my sense of myself as a woman. I've been struck by how many fellow prolapse sufferers have described themselves as feeling like a "freak" or an "alien." I, too, have shed oceans of tears at this sensation of being "broken." I resent horribly the loss of everyday pleasures like being able to take my baby for a stroll or cook a nice dinner without it causing me pain. The drain on my energy and the difficulties in lifting have also often made me sad because prolapse is hurting my ability to be the best mother I could be. I think these are all pretty common emotional reactions. In addition, I have a problem that is peculiar to my own situation: The anger and grief I've felt have made it more difficult to work on my research project, because its topic - the history of pregnancy and childbirth - cuts too close to home.

My husband and I would like to have a second child, but I'm afraid of how hard it could be to carry a second pregnancy. I was very nauseated through half of my first pregnancy and wonder how I would cope with that again and the prolapse symptoms to boot. I'm not much concerned about the delivery - I've heard that it often is quick in women with prolapse - but I do worry about the prospect of trying to recover afterwards, this time with two wee ones to care for. Perhaps hardest of all, another small child would also mean putting off surgery for a couple of additional years. That said, we are still considering baby number two. As much as I hate dealing with the prolapse, I think it might be even worse to look back someday and see that it had stopped me from doing something I really wanted to do. I am much encouraged by other women who have reported successful pregnancies with no obvious additional damage to their pelvic supports.

The final issue is surgery. I wish I could just "get fixed" tomorrow, but it isn't that simple. Since heavy lifting can cause everything to fall again, it makes no sense to me to go under the knife before I'm done lifting children. I hope to avoid becoming one of the many women who end up having repeat surgeries. I also hope that laparoscopic techniques will have been improved enough five years from now that uterosacropexy can be performed just as successfully through tiny incisions. It's not just the shorter recovery that makes me hope for this, but also the prospect of less scarring and fewer adhesions (which would also be important if, heaven forbid, I ever did need a repeat operation). I'll want to pick the surgeon carefully because rectocele repair (which I really will need if I hope to feel much better) is a tricky matter.

For those of you who are new to the wonderful world of pelvic prolapse, I have a few words of advice: Find a urogynecologist who listens to you, takes you seriously, and examines you in various positions (especially upright). Even if you are looking at surgery sooner rather than later, be assertive in trying out a pessary (and be patient if the first fitting doesn't give you the right pessary). Talk to other women in this position; it will help you with both information and emotional support. Educate yourself as much as you can on both the causes of prolapse and its treatments. The more you know, the less helpless you will feel - and the more hopeful.

In closing, I would like to say that I do not blame any of my physicians personally for what has happened. I think I should have been given information on the risks of vacuum extraction, had a c-section instead due to my risks, and been offered a pessary at my six-week postpartum checkup. But in my view, the problem is not one of individuals' failings (though no doctor is perfect). The problem is a systemic one in the obstetric/gynecological profession. Medical students are taught that pessaries are only for the elderly, and they learn otherwise only when educated by patients or more enlightened colleagues. Obstetricians are coming under pressure to reduce the c-section rate, but they have few criteria for how to do so. Fear of lawsuits drives the way doctors "manage" labor, with the long-term health of the mother generally a very minor factor in delivery-room decision-making. All told, far too little hard, scientific data is available on the causes of prolapse and its most effective treatments.

I hope that, as the baby boom generation of assertive women moves into menopause and experiences what could be an epidemic of pelvic floor dysfunction, we women will raise our voices and press the medical profession for what we need: Better and less invasive surgical techniques that let us keep our healthy organs. Solid studies on the best treatments for pelvic organ prolapse, surgical and otherwise. Doctors who take our symptoms seriously and don't scoff at premenopausal women who suffer prolapse. And - for the sake of the next generation - a clear understanding of how better to prevent prolapse.