In this Q&A, Erin Nesbitt-Hawes, an obstetrician and gynaecologist with Alana Healthcare for Women, which provides obstetrics, gynaecology and allied services for women’s health issues, discusses some of the injuries that can occur in childbirth.
What are the risks of incurring a pelvic floor injury through a vaginal delivery?
Unfortunately, injury to the pelvic floor is a common outcome following vaginal delivery. Studies show that women having their first baby have a 75 per cent chance of experiencing some trauma to this area.
What types of injuries are associated with a vaginal delivery?
There are three main types of injuries that can occur in childbirth. These include:
- Levator avulsion, where the sling muscle that goes from the pubic bone at the front and encircles the vagina and anus is torn from the bone. This injury predisposes women to prolapse in the short or long term and is particularly difficult as there is no definitive surgical treatment. The biggest risk factor for having a levator avulsion is forceps delivery with between 20 and 40 per cent of women affected.
- In addition to the levator muscle complex, the fascia which lies between the bladder and the vagina, or the vagina and the bowel can be torn during childbirth. This layer can be thought of as a canvas-type layer which helps to support the organs at the front and back walls of the vagina. Tears in this layer can result in prolapse symptoms. Surgical repairs to this area are also difficult as when the defect is brought back together with stitches it can expose or pull on other areas of weakness in the canvas layer and create new areas of prolapse later on.
- Tears to the anal sphincter, otherwise known as third or fourth degree tears. These are usually diagnosed at the time of delivery and repaired at the same time. While recovery may be complete following repair, some women experience ongoing problems with control of the passage of wind or occasionally stool following this type of injury.
What are some of the symptoms that a woman might experience following childbirth?
Symptoms that a woman may experience following childbirth can include a sensation of prolapse or bulge within the vagina, incontinence which can be related to passing urine or bowel opening, and pain within the vagina, which can include painful sexual intercourse. These issues are often embarrassing for the woman and she may be reluctant to seek help. Not much information is given in the usual course of antenatal care about what to expect from injuries associated with childbirth and so many women are confronted by symptoms that they didn’t expect and don’t know if they are normal.
If a woman is experiencing any of these symptoms, what should she do?
There are lots of ways to get help should you suffer any of these symptoms after having a baby. The first port of call is usually your GP or your obstetrician and the six-week check-up is a good time to discuss any symptoms you may be experiencing. As well as checking how everything is healing, your pelvic floor muscle strength can be assessed at this time.
Where there are issues, usually a referral to a specialist women’s health physiotherapist is the next step. Instruction in muscle-strengthening exercises such as Kegels and bladder techniques can help to resolve symptoms in many cases.
The other thing that often improves with time is the hormonal environment within the vagina which is low in oestrogen when you are breastfeeding, often making the symptoms worse. Following reduction or cessation of breastfeeding as your baby grows older symptoms may continue to improve.
What are pessaries?
Pessaries are silicon devices which may be shaped like rings, cubes or discs and are inserted in the vagina to help support the tissues for women with prolapse. Women can be trained to insert and remove these themselves and some women wear a pessary only when exercising, or when they know they will be on their feet all day.
Is surgery an effective option?
Sometimes referral to a gynaecologist or urogynaecologist specialising in this area is required for consideration of a surgical option to resolve the issue. This is usually a last resort if other measures have not been effective, as surgery may not have a long-term benefit due to high rates of symptom recurrence. Surgery is never recommended prior to having all of your children as there is a risk the repair will be torn again during the next pregnancy or delivery.
Although caesarean delivery might be thought of as an answer to all of these issues, unfortunately that is not always the case. In the short term after having a baby there has been shown to be a reduced risk of both urinary incontinence and prolapse by having a caesarean delivery. Over the longer term though the two groups even out as other factors such as genetic predisposition of the tissues and lack of oestrogen hormone after menopause become more prominent.
What would you say to a woman who is feeling worried or confused about pelvic symptoms she may be experiencing after childbirth?
If you find yourself with issues after childbirth, know that help is available. Please don’t be too embarrassed to seek help.
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