Un­spo­ken taboo a part of child­birth

Tear­ing has tripled in past 10 years

The Star Early Edition - - NEWS - CARO­LINE SCOTT

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

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