Unspoken taboo a part of childbirth
Tearing has tripled in past 10 years
THE arrival of a longed-for first baby is one of the happiest events in a woman’s life. But for some mothers, birth is so physically and emotionally traumatic, it casts a life-long shadow.
Many women will tear to some degree during childbirth, but the numbers sustaining this devastating, life-changing damage are, alarmingly, rising. The rates for severe tears have tripled in the 10 years to 2012, according to the Royal College of Gynaecologists and Obstetricians.
It suggests six in every 100 women giving birth for the first time in the UK will experience a severe tear (the rate among women who’ve already had children is lower).
But Professor Michael Keighley, a colo-rectal surgeon previously based at Queen Elizabeth Hospital in Birmingham, believes the college is wrong and the real figure is far higher: “So many of these injuries are missed, most of us believe the real number is more like 10% of all first-time mothers,” he says.
Keighley, who has previously worked in India repairing injuries caused by childbirth, was so concerned about the situation in the UK that last year he set up the Masic (mothers with anal sphincter injuries in childbirth) Foundation.
As well as problems with incontinence, there may be a “multitude of psychological effects including anxiety depression and post-traumatic stress disorder”, he says. “It’s a huge problem, it ruins women’s lives and yet no one is talking about it.
“Gynaecologists and midwives almost never see these mothers after delivery. And women are often too ashamed to seek help because they feel dirty. It is a completely unspoken taboo.
“Much, much more must be done, both to prevent it and to identify it when it occurs.’
The average age at which women give birth in the UK has been rising for decades, while babies have been getting bigger – both key risk factors for severe tears. The risk of damage from natural delivery increases with age as muscles and ligaments get less stretchy.
For every year over the age of 18, the chance of an anal sphincter tear goes up by 6%, according to research published in the American Journal of Obstetric Gynaecology last year.
And instrumental delivery – using ventouse or forceps – increases that risk further.
A review of studies involving 20 million births makes the picture crystal clear: the odds of having an anal sphincter tear are 6.7 times higher with forceps, and 2.7 higher with ventouse compared with normal delivery, yet experts say women are not routinely warned of the risks in these procedures.
“The main problem in maternity care is that we keep far too much information from women,’ says Professor Hans Peter Dietz, a world-renowned obstetrician and gynaecologist based at Sydney Medical School.
“We treat them like children rather than competent adult patients – this does not happen in any other area of medicine.
“We still talk about “natural birth” yet human reproduction has become very, very unnatural.
“The average age women give birth for the first time is now well over 30.
“Labour doesn’t start as efficiently when you’re older. And tissues are stiffer, so you’re more likely to suffer a major tear that causes long-term, unfixable damage.”
Using 3D and 4D ultrasound, Dietz and his team have been able to accurately identify the true extent of the problem.
“We now realise that major damage in labour is common – between 30% and 40% of women with sphincter tears also have levator ani avulsion (where the pelvic floor muscle detaches from the pubic bone).”
He says this occurs in more than 40% of forceps deliveries but “these injuries are usually overlooked.
“Given that patients are warned of risks as low as one in 1 000 before routine varicose vein surgery, it is incongruous not to warn a woman having her first child at 38 that she has a 15% chance of an anal sphincter tear,” he adds.
“She has a right to know. And we have a duty to tell her so she can decide what kind of risk she is willing to take.
“Up until now, we have failed dismally.”
Dietz believes obstetricians have been bullied into risky practices by the drive to keep the caesarean rate under control.
“I have yet to see a woman permanently damaged by an elective Csection, but I see about five women a week damaged for life, mainly because of forceps used to avoid a caesarean section.”
Maureen Treadwell, co-founder of the UK Birth Trauma Association, says the “worst scenario” is when, to avoid a caesarean, an older woman with a large baby is put through a “normal” birth.
“She’s much more likely to tear, yet it’s highly likely she won’t have been informed of those risks.
“She may appear to have had a ‘successful vaginal birth’ – gynaecologists and obstetricians don’t see these mothers 18 months later, on a waiting list for a colostomy because they are incontinent.
“What’s certain is that the health service is not saving money by avoiding caesareans.
“Pelvic floor repair and colorectal surgery is incredibly expensive and some of these woman have four or five surgeries, at around £3 000 (R50 000) each.”
Although the royal college insists consent is always sought before instrumental deliveries, in practice, few pregnant women understand the risks, says a study published in the Nursing Times this year by Wendy Ness, a colorectal nurse specialist at Croydon University Hospital.
She found that women were unaware of the risk of severe tears and when they do occur, they weren’t informed of the long-term consequences.
She also found waterbirths to be a factor because the position of the mother means the perineum – the area between the genitals and anus – is hidden, which can lead to unrecognised tears. – Daily Mail