The GREAT childbirth TABOO
Every year thousands of new mothers suffer life-changing injuries that CAN be avoided. So why’s no one talking about . . .
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.
Carol Sunnocks, from Paisley, Renfrewshire, describes her gorgeous ten-year- old son Kai as ‘my world, my joy, i love him with all my heart’.
But like thousands of women, Carol is living with life-long damage as a result of natural childbirth because hospitals didn’t warn her of the risks, or offer a caesarean.
During Kai’s delivery, Carol, now 48, sustained a severe tear; ten years on, she still has little control over her bowels.
She has bravely agreed to talk about her experience in the hope that other women who are affected won’t feel as desperately isolated as she did — and to highlight the need to inform mothers-to-be about the risks, so they can avoid her plight.
Many women will tear to some degree during childbirth, but while it would be comforting to imagine injuries such as Carol’s are rare, the numbers sustaining this devastating, life- changing damage are, alarmingly, rising. The rates for severe tears have tripled in the ten years to 2012, according to the Royal College of Gynaecologists and Obstetricians (RCOG).
They suggest 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 colorectal surgeon previously based at Queen elizabeth Hospital in Birmingham, believes the RCOG is wrong and that the real figure is likely to be far higher: ‘So many of these injuries are missed, most of us believe the real number is more like 10 per cent of all first-time mothers,’ he says.
Professor 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 (PTSD)’, 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.’
What makes Carol’s story so poignant is that, in obstetric terms, Kai’s birth was a success — mother and baby left hospital alive — but her story exposes an NHS maternity system some experts believe is failing women on a catastrophic scale.
WOMEN UNAWARE OF THE RISKS
Kai was born on March 28, 2007 weighing 5lb 9oz. Carol’s labour had begun to slow down and it was decided — but not discussed with her or husband, Stephen — that ventouse [where a suction cap is fitted on the baby’s head] would be used to deliver him.
afterwards, as she cuddled Kai, Carol was told she had a minor tear needing a few stitches. in fact, she had another, 6cm tear in the back of the vaginal wall that had been missed; the following day, she needed emergency surgery and four pints of blood.
For the first year of her son’s life, Carol couldn’t leave the house. ‘i had to buy special incontinence pants and would get through six or seven pairs a day. i’d even have accidents lying next to my husband in bed.
‘it was horrific, i have never felt so frightened and so utterly alone. it affected every aspect of my life,’ Carol recalled.
But it wasn’t until april 2009, after 13 months of incontinence, that her gynaecologist referred her to a colorectal surgeon, who diagnosed a tear caused by the ventouse. The ring of muscle that helps control bowel movements, the anal sphincter, had been damaged.
Carol had surgery and was fitted with an ileostomy bag — which the small bowel empties into — to give the anal muscle time to recover.
But it was beyond repair. Six months later when the bag was removed, Carol began having accidents again. ‘There’s nothing i can do about it. My husband is incredible, but it’s ruined our relationship,’ she says.
‘i’m not the person i was. Before Kai was born, i was a children’s support worker in a woman’s refuge and studying for a postgraduate degree in play therapy. i had to give all that up. There’s so much sadness over everything i’ve lost. i imagined when i brought my baby home, it would be all banners and balloons, but i wasn’t able to celebrate then and i haven’t been able to give my son a normal life.
‘When i lose control, he gets embarrassed. it breaks my heart because i want him to be proud of me. No mother or child should have to go through this.’
Carol, who belongs to Facebook group Birth injury Mammas, says there is ‘ total silence’ on the subject. ‘No one talks about it, not doctors or the other mums in your NCT group.’
FORCEPS LINKED TO DAMAGE
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 deliv- ery 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 per cent, 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
ecome very, very unnatural. The verage age women give birth for he first time is now well over 30. abour doesn’t start as efficiently hen you’re older. And tissues are tiffer, so you’re more likely to uffer a major tear that causes ng-term, unfixable damage.’ Using 3- and 4D ultrasound, Prossor Dietz and his team have een able to accurately identify the rue extent of the problem. ‘We ow realise that major damage in abour is common — between 30 nd 40 per cent of women with phincter tears also have levator ani avulsion [where the pelvic floor muscle completely detaches from the pubic bone].’
He says this occurs in more than 40 per cent 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 per cent chance of an anal sphincter tear,’ he adds.
‘She has a right to know that. 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.’
DRIVE TO CURB CAESAREAN RATE
Professor Dietz believes obstetricians have been bullied into risky practices by the drive to keep the caesarean rate under control — caesareans cost around £1,700 compared with £750 for a normal birth. ‘I have yet to see a woman permanently damaged by an elective C-section, 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 each.’
WATERBIRTHS ARE A FACTOR
ALTHoUGH the rCoG 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 longterm 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.
Amanda Maclellan, 35, was given no choice over how she wanted her babies delivered. ‘ We were told that because I was expecting twins, the birth would be consultant-led, but the babies were delivered by a senior house officer — a relatively inexperienced doctor.
‘I’d been in labour for 13 hours and pushing for three when I was told they were going to use forceps.’ She describes being ‘pulled down the hospital bed’ by the force exerted, but was reassured it was a ‘difficult but standard delivery’.
The first baby, a girl, was delivered by forceps at 3am weighing 6lb 5oz. Amanda managed to push out her brother, who weighed 7lb 5oz, four minutes later.
It was apparent almost immediately she no longer had control of her bowel. ‘I wore really horrible, disposable pants — but there were lots of accidents and I lost my dignity completely.
‘I felt humiliated and so alone — I couldn’t go out, I couldn’t talk to any of my friends. I remember everyone saying how lucky I was to have two healthy babies, but I didn’t feel lucky. I felt suicidal.’
Despite her injuries, Amanda, who lives in Scotland, was not offered a hospital follow- up appointment. Gentle questioning by her health visitor resulted in a referral for women’s physiotherapy; she was given disposable ‘plugs’.
‘They’re not comfortable, but they gave me back some dignity and allowed me to get back to my old job in a craft shop.’
But the idea of sex was terrifying. ‘I knew I should try, but I just couldn’t,’ she says. ‘After a year, I felt I couldn’t carry on any longer.’
And on her 27th birthday, Amanda had a colostomy operation. ‘It was such a huge decision, but it felt like the best birthday present in the world,’ she says. ‘for the first time in over two years, I didn’t have to worry.’
Amanda, whose legal case against the hospital is ongoing over a decade later, says that for her ‘and many other women, childbirth wasn’t “natural” — it was a brutal and violating experience. Prior to my diagnosis, I’d never heard of a tear like this, or any risk factors.’
She is still having counselling for PTSD, and inevitably, her relationship with the twins has also been affected. ‘I spend a lot of time feeling deeply guilty because of the time this has taken away from them.’ She, like Carol, would love to have had more children, but both are too traumatised.
over the past 30 years, the use of forceps in the U.S., Sweden and Germany has dropped to 1 per cent of births. In Denmark, where there hasn’t been a single forceps delivery for 14 years, 30 per cent fewer women suffer from womb and rectal prolapse in later life.
The UK is one the few places where the forceps rate is rising — doubling from 3.5 to 7 per cent over the past five years, according to the rCoG.
Professor Dietz estimates that women in the United Kingdom are exposed to a 30 to 40 per cent greater risk of levator ani damage and anal sphincter tears than women in the U.S. or Germany.
‘forceps are the perfect boy’s toy, the symbol of the competent obstetrician. In my career, I have performed hundreds of forceps deliveries and unknowingly, damaged at least 50 women for life. We’ve been dreadfully ignorant.
‘But there is now no excuse for not sharing what we know. As a profession, obstetricians have been betraying women’s trust to an absolutely staggering degree for decades by not disclosing the risks.’
Professor Alan Cameron of the rCoG argues: ‘Whether a baby should be delivered instrumentally is a matter of clinical judgment.
‘Many women will elect for it given the longer recovery and downstream health effects associated with caesarean section.’
THE MOVE TO SAFER BIRTHS
IN JANUAry this year the college launched a Care Bundle for obstetricians and midwives which it hopes will help reduce the numbers of severe tears.
This includes, for instance, advice on good practice such as warm compressions and the midwife ‘supporting’ the perineum with her hand as the baby is delivered, found to significantly reduce the incidence of severe tears.
‘It does not seek to analyse the relationships between tears and different modes of delivery, but to improve and standardise care within the units for all vaginal deliveries,’ Professor Cameron explains, adding that it’s been piloted in two sites in england ‘with promising results’.
Both Carol and Amanda feel strongly they don’t want to frighten pregnant women, but instead, arm them with the facts, so they can feel safe wherever they deliver.
‘At no point did anyone say: “If your baby can’t be delivered normally, and we need to assist you, how would you like that to happen?” ’ says Carol. ‘If the risks has been explained I would have asked for a caesarean.’
She now has a pacemaker in her back, which emits electrical pulses to help strengthen muscles that regulate bowel function. It cost the Nhs £15,000, but Carol remains incontinent. ‘I lost my job because of this, and my dreams of being a great mum,’ she says. ‘It breaks my heart to think other women are still going through this.
‘I put my trust in doctors, but life as me, Carol, ended the day my son was born.’