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.

Is it a good idea to reduce the caesarean rate?

Caesarean section rates in western countries have been rising for a long time – but the rate varies widely between different countries. In Sweden, for example, it’s 17%, while in Cyprus it’s 52%.

It’s not at all clear why rates differ so much. Reasons often cited for high caesarean rates include: the increase in older first-time mothers (for whom pregnancy and labour is riskier); the increase in overweight mothers (ditto); the fact that babies are getting bigger; a trend for women to request a planned caesarean section; increased medical management of labour, which sets labour on a path culminating in emergency caesareans; and a cautious approach by doctors who fear litigation.

This is informed speculation, however: the only way to know for sure would be to record and collate the reason for every caesarean section, and that doesn’t seem to happen. I am slightly sceptical of the idea that the increase is down to women requesting the procedure. It provides a handy narrative and another pejorative term for women (“too posh to push”) but the truth is that the majority of caesarean sections are performed as an emergency procedure, and there are often medical reasons for planned sections (breech presentation, placenta praevia).

Does it matter?

This is the interesting question. In Australia, one in three babies is born by caesarean, one of the highest rates in the world. There is pressure to reduce the rate: caesareans, it is argued, pose an increased risk to the mother and baby. An article in the Sydney Morning Herald quotes Andrew Bisits, the medical co-director of maternity services at the Royal Hospital for Women in New South Wales:

“People forget that a caesarean is a relatively major operation. It’s an instant trauma to the body. It’s anything but keyhole surgery. I think that fact sometimes gets lost and people forget that you can get through a normal birth with no scratches or just a few scratches.”

In New South Wales, a policy to reduce the c-section rate and increase the “normal” birth rate has been unsuccessful, with c-section rates remaining fairly static. According to the Herald article, there has even been an increase in the number of women having induced labour and forceps deliveries. More women “are having major haemorrhages after they give birth.”

One obstetrician, Professor Hans Dietz, argues that the “increasing push towards natural birth is having the unintended consequence that more women are having longer, more difficult labours”. He says:

“In the past it was two to three hours of unsuccessful pushing before obstetricians intervened, now it may be six. It has the advantage that some women will push their baby out, but the risk that some will be left with a post-partum haemorrhage.”

The article goes on:

“He estimates that for every 10 caesareans prevented, it is likely that four additional tears to a woman’s levator muscle – which holds the pelvic organs and bowel in place – occur, and four additional sphincter tears.”

Dietz is also sceptical about the oft-cited dangers of caesareans:

“In my entire clinical life, how many women with major later life health problems due to caesarean have I ever seen? I can’t remember a single one. How many after forceps will I see? Several a week, at least 100 a year, maybe 200 a year,” he says.

So, is the drive to push down the caesarean rate misguided?

The short answer is: I don’t know. I suspect that nobody else does either. The Herald article demonstrates that people who work in maternity services have vastly differing views on the subject.

For women, it’s bewildering. Few, I imagine, are delighted at the prospect of surgery to deliver their baby; but even fewer want what Dietz describes as the potential consequences of a difficult vaginal birth: “urinary and fecal incontinence, prolapse, sexual dysfunction, years or decades later.”

What we need is more data: why caesareans are performed; the health consequences for women (and their babies) who deliver this way; whether reducing the caesarean rate results in better outcomes for women and their babies; the particular factors that lead to an assisted delivery; the physical and mental health consequences for women and their babies who have an assisted delivery; the correlation between factors such as age, weight and social class and method of birth.

Until we have that data, women will continue to be the unwitting victims of an argument that rages between professionals without coming to a satisfactory conclusion.