Birth Trauma Consultancy

During childbirth a proportion of mothers may sustain severe damage to vaginal structures that cause adverse physical consequences. Although, vaginal injury was poorly identified prior to the introduction of imaging technology in the 21st Century, recent studies report TWO different types of serious damage that include: pelvic floor damage and perineal tearing. Currently, this research has been poorly disseminated in maternity settings. Some women suffer from both injuries. (Skinner et al 2015, Skinner et al, 2018.)

Currently, both forms of injury are often synonymously described as perineal damage. This is inaccurate and confusing to women. The following definitions are correct:

• Pelvic floor damage occurs during complicated deliveries, when an internal pelvic floor structure, called the levator ani muscle (LAM) becomes detached from one or both sides of the pubic bone and, can result in pelvic organs prolapsing into the vagina e.g. bladder, bowel and/ or uterus.
• Perineal injuries are well known and can involve minor tearing with minimal consequences but severe damage may result in faecal incontinence. Injury occurs during the crowning of baby’s head and affects the area between the vagina and anus.

(Skinner et al 2015, Skinner et al, 2018.)

Mothers who experience traumatic birth events and/ or debilitating physical effects of vaginal damage can also suffer from symptoms of posttraumatic stress disorder (PTSD) that include: avoidance of birth related issues in everyday life; panic attacks; hypervigilance; detachment from partners & friends; poor bonding with baby; nightmares; feelings of numbness; flashbacks/reexperiencing traumatic birth events. (Skinner et al, 2018.)

Current research reveals that severe vaginal birth damage is more common than previously realized and, often poorly identified. Prevalence rates of the following TWO distinct forms of injury involve:

• 13 to 36 % of first-time mothers in developed countries who are affected by pelvic floor damage from levator ani muscle detachment (Skinner et al 2015)
• 4 to 6 % of mothers who sustain major perineal injuries or 3rd and 4th degree tearing(Harvey et al, 2015)

There is no simple answer to this question but the following may explain contributing factors:

• Pregnancy and birth are normative events in society and often positive for a proportion of women.
• Up until the introduction of imaging in the 21st Century the effects of vaginal injuries were poorly understood.
• Recent research findings have not been disseminated to maternity clinical settings
• Consequences of both types of damage are embarrassing for women to explain and a taboo topic.
• Women often remain ‘silent’ and mistakenly believe they have failed as mothers and feel stigmatized. (Skinner et al 2015, Skinner et al, 2018.)

You may need to get a referral from your GP to an imaging urogynaecologist if you experience the following:

• Bulging in your vaginal area that is exacerbated by standing for long periods and lifting.
• Problems with urinary or bowel incontinence.
• Severe constipation that is not improved by diet, Kegel's exercise & laxatives.
• Sex is impossible due to the above consequences of birth damage.

(Skinner et al, 2018.)

This service assists women to access birth trauma clinicians and improve their confidence in discussing effects of birth damage. It is ideal if you can attend appointment/s with your wife/partner regarding her accurate assessment of physical and /or psychological trauma, so the clinician can explain relevant issues to both of you. Otherwise, it is difficult understanding a partner’s consequences without medical guidance. The following may help:

• Notice whether she finds lifting objects or standing for extended periods difficult.
• Observe whether she has nightmares, avoids talking about her birth, or appears emotionally detached.

This may be dependent on marital communication and how soon after birth you have sex. The following may help:

• Healing could take more than 6 weeks and/or up to several months.
• Women who have vaginal prolapses often find sex very confronting. Most report that if they have sex, the bulging sensation in the vagina, lower back pain and/or numbness are all distressing. If they suffer from perineal tearing as well, pain may be very overt if the wound has not healed.
• More information is provided by the birth trauma expert, who will discreetly discuss individual needs with affected women and/ or partners and, provide access to informed clinicians for treatment options.

This is dependent on many factors that include suboptimal validation of birth injuries, but the following experiences of women may assist:

Recently published interviews with 40 women, who were diagnosed with severe pelvic floor damage and perineal injuries, revealed that more than 2/3 suffered from 3-4 symptoms of postpartum PTSD including: panic attacks/anxiety; hypervigilance; detachment from partners, poor bonding with baby; nightmares; numbness and flashbacks/reexperiencing of traumatic events as per DSM-5.

Postnatal depression (PND) was not detected in this cohort and the Edinburgh Postnatal Depression Screening (EPDS) was not efficacious in revealing symptoms of postpartum PTSD. (Cox 2017)

Contributing factors will be further discussed by the trauma expert, who can also improve access to an expert mental health clinician for assessment. (Skinner et al, 2018.)

• Acquired health knowledge that enhances confidence and communication skills to make informed decisions about health improvements.
• Understanding of evidence based information that optimizes access to health care.
• Verbal and written educational sources that cater for varying cognitive and social abilities of individuals. (W.H.O. 2020.)