Severe tearing in childbirth – not just a physical problem

NB I’ve edited this post to clarify that Liz Skinner’s research focuses primarily on women with damage to the levator ani muscle rather than with obstetric tearing.

A traumatic vaginal birth in which the levator ani and external anal sphincter muscles are damaged can cause mental health problems, including post-traumatic stress disorder (PTSD), according to a new study from Liz Skinner. About half the women also had severe tearing.

About 90% of women experience tearing during childbirth, but most are first or second degree tears, which are relatively mild and heal quickly. Approximately six percent of women have third or fourth degree tears that can damage the anal sphincter. Skinner and Hans Peter Dietz have also pioneered research into damage to the levator ani muscle (LAM), which can be devastating for women. The argue that the problems of a difficult vaginal birth tend to be overlooked in the drive to reduce caesarean sections, which are usually perceived as more risky for both mother and baby.

The study identified 40 first-time mothers with major pelvic floor trauma and interviewed them one-to-four years after they gave birth. Just over half (22) of the women had “major obstetric anal sphincter tears.”

Of the 40 women, 35 had “Multiple symptoms of pelvic floor dysfunction” causing lifestyle alteration. These symptoms included “urinary or fecal incontinence, prolapse, chronic pain, dyspareunia [painful intercourse]”.

It’s hardly surprising, then, that 27 experienced PTSD symptoms, including “poor baby bonding, flashbacks during sex, dissociation, avoidance, anxiety”.

Probably the most worrying themes to emerge from the study were the lack of awareness or communication from health professionals:

• 36 women said there was no information provided by clinicians on potential postnatal pelvic floor morbidities
• 36 said that there was no postnatal assessment of their injuries
• 26 said that they experienced “dismissive reactions from poorly informed clinicians to maternal injuries. One woman said: “The midwife said that this was OK… but I knew that it was not normal… The doctors really did not understand the situation… I was in shock – devastated and unable to get any health professional to understand.”

Although the study was carried out in Australia, I’d be surprised if a UK study didn’t find something similar. I’ve now heard numerous stories about obstetric tears not being treated properly or women having their concerns dismissed as unimportant. One of the problems is that midwives often don’t see the consequences of tearing in childbirth – women are only under midwife care for 10 days after birth, so if a tear has failed to heal properly weeks, months or even, shockingly, years after birth, they’ll be dealt with by another group of health professionals entirely. So midwives may well assume, wrongly, that a tear during childbirth has healed without problems.  That may lead to an unjustified confidence that obstetric tearing isn’t a significant problem. And because LAM damage is impossible to detect without ultrasound, LAM problems are generally undiagnosed and therefore untreated.

As I’ve already reported, the RCOG is now campaigning for better understanding of obstetric tearing in childbirth, and better care for the women who experience it. But we still have a long way to go – and In the meantime, a lot of women are suffering in silence.