The birth of your baby is meant to be momentous and exciting. Many pregnant women devote much time to planning or considering how they want their birth to go. But what happens if things don’t go to plan? For the one in three Australian women who suffer birth trauma this is the reality, leaving them with physical and emotional consequences, which sometimes last for years.
How the medical community defines birth trauma may be quite different to how many women describe their experience. For the medical team, birth trauma usually involves a serious complication, which can then cause physical damage to the mother or baby. This can include postpartum haemorrhage (lots of bleeding after delivery), large perineal tears, or shoulder dystocia (when the baby’s shoulder gets stuck behind the mother’s pubic bone during delivery).
However, many women may describe their delivery as traumatic, despite more textbook birth histories. This may still include seemingly more minor physical trauma, such as tears, or scar healing issues. But many also describe emotional or psychological trauma from their delivery, especially if things did not go as they had planned. Partners can also experience birth trauma.
Let’s explore the different types of birth trauma more closely. I will only cover those aspects that effect the mother, not the baby.
Childbirth is still one of the riskiest experiences many women will undergo in their lives. There are a number of different types of physical trauma women can experience during childbirth, and they are more common than you think. In the following information, the statistics quoted specifically relate to Australia.
Perineal tears are tears in the region between the vagina and anus (the perineum) and are graded from 1 (smallest) to 4 (largest). Grade 3 tears are further broken down into 3a/b/c depending on how far they extend, with 3c being larger than 3a. Most doctors would usually only rate 3rd and 4th degree tears as birth trauma, as these tears extend to the anal region, and carry the greater risk of ongoing complications, including an increased chance of bowel incontinence. Thankfully, they only occur in about 3-4% of all vaginal deliveries. You are at greater risk for a 3rd or 4th degree tear with your first birth, if you push for longer than an hour, if you have an instrumental delivery (especially forceps), and if your baby is over 4kg or is posterior. However, even smaller tears can be quite tender and some women find the resultant scar on the perineum can remain sensitive. Around 85% of vaginal deliveries will result in some degree of tear.
Levator avulsion involves a deeper tear of the pelvic floor muscles where they attach to the pubic bone. This may not be obvious from the outside. Sometimes the muscles are over-stretched or partially torn rather than fully torn. Levator avulsion can occur in 10-30% of vaginal births depending on your delivery type. Forceps deliveries carry a much greater risk for this problem. Levator avulsion was an unrecognised form of birth trauma until more recent years and may still not be identified a long time after the delivery. Because levator avulsion creates a greater gap under the pelvic organs, the most common side effect of levator avulsion is pelvic organ prolapse.
Pelvic organ prolapse is descent of one or more of the pelvic organs, creating a bulge, lump or heavy feeling in the vagina. Up to 50% of women who have had a baby, regardless of delivery type, may have a prolapse, however many will never have symptoms. Around 20% may need surgery. Prolapse commonly presents much later in life – but there are some women who develop prolapse symptoms shortly after their delivery.
Scar problems can include problems with scar healing or a scar that remains sensitive even after healing well. This can occur with perineal scars or Caesarean scars. Up to 11% of women complain of ongoing scar sensitivity after a C-section. Scar pain can cause problems with mobility, carrying out daily tasks or painful intercourse (dyspareunia).
Postpartum haemorrhage is defined as blood loss of more than 500ml with delivery and is a medical emergency. This often occurs during or within hours of delivery. Some women may require a blood transfusion, emergency surgery or intensive care treatment following a postpartum haemorrhage.
With or without physical injuries, many women will report emotional or psychological distress related to their birth experience. This can occur for various reasons.
Some women feel a sense of failure if their delivery did not go according to plan, even if this may have been for reasons outside of their control. This may be experienced, for example if an emergency C-section was required, when a natural delivery had been planned. However, any type of unplanned or unforeseen event during delivery may trigger these feelings.
Sometimes, poor communication between the woman and her midwifery or medical team, can leave the birthing mum to feel they were not consulted about their birth options, or things occurred that they did not want or did not understand.
Any of these experiences can lead to ongoing problems such as postnatal depression (PND), postnatal anxiety, or even post-traumatic stress disorder (PTSD). The new mum is not the only one who can suffer from emotional or psychological trauma either. Up to 10% of partners may also suffer PND. For some women, the psychological aftermath of their birth can take years to overcome.
As we saw above, even with our amazing modern medicine, childbirth is not without its risks, and not all trauma can be prevented. Quite often during labour, when things do go wrong, they can progress very quickly, and rapid decisions need to be made for the sake of the mother and baby.
It is therefore really important that all women should have a good conversation about ALL the possible options before their birth. This discussion is part of the process of informed consent, which should occur before any procedure. It is great to share with your doctor or midwife how you would ideally like the delivery to go. However, you should also encourage a discussion about what may happen if things don’t go according to your plan. Try not to be scared by this, but rather think of it as a chance to educate yourself about what interventions may be needed. Ask lots of questions about benefits and risks of each intervention. This is also your opportunity to discuss the kinds of interventions you really want to avoid if possible. That doesn’t mean they won’t be used in a medical emergency, but it does mean the medical team may consider other options earlier. Whilst this kind of communication will not necessarily prevent physical birth trauma, it may help to prevent or reduce emotional or psychological trauma associated with not knowing or understanding what “may” happen.
It can also be helpful to go into any delivery as fit and healthy as you can be. There are plenty of statistics to show fitter women not only cope better during labour themselves, but so do their babies. Continuing to exercise during your pregnancy, eating well and getting plenty of rest before the big day can all make a difference.
Finally, if you are unfortunate enough to suffer any kind of birth trauma, having good support afterwards is essential. It is sad how often women will report their partner or family does not seem to understand what they are going through. For physical birth trauma, a Women’s Health Physio who has a special interest in postnatal care can be really helpful to guide your recovery. If you have emotional or psychological trauma, a psychologist with a special interest in perinatal care is of great benefit too. Your GP should be able to help you find someone for your particular needs. Some women also feel it is really helpful to talk with someone who has been through the same kind of experience they have had. This is where the Australian Birth Trauma Association can be an excellent resource. Their website has lots of helpful information, and they also offer access to a peer mentor, who can help support you through your recovery.
The important thing to know is that if you have birth trauma, you are not alone and there is help available. Yes - not all births go according to plan, but that doesn’t mean you can’t ultimately have a happy ending.
If you have any questions about the content of this blog or would like more information, please contact me at Life Cycle Physiotherapy.