To hear natural childbirth advocates tell it, vaginal birth is an unalloyed good.
The truth is rather different. Normal vaginal birth can lead to a lifetime of serious, embarrassing and life altering problems. Incontinence, among other issues, is an entirely natural consequence of an entirely natural vaginal birth.
As a newspaper piece from New Zealand notes, We need to speak more honestly about traumatic births:
[pullquote align=”right” color=””]Incontinence is an entirely natural consequence of an entirely natural vaginal birth.[/pullquote]
It ruins sex lives and destroys marriages, stops women from engaging in physical activities and even prevents some types of paid work. Although common, many women are so embarrassed by it that even their partners and closest friends are unaware of the problem.
It’s the injury that can result from a vaginal birth.
New research presented last week at the International Continence Society in Montreal about the psychological consequences of traumatic vaginal birth suggests that between 20 and 30 per cent of first-time mothers having a vaginal birth will suffer severe and often permanent damage to their pelvic floor and anal sphincter muscles. There can also be major psychological consequences of traumatic vaginal birth.
Conditions range from life-long urinary and faecal incontinence, painful sex, genital prolapse, body image problems and emotional trauma.
To understand why these problems develop we need to understand how the pelvic organs are held in place.
Ever wonder why the uterus doesn’t fall down through the vagina? It’s partly because of ligaments that hold it in place in the pelvis, but it’s mostly because of the muscles of the pelvic floor that form a sling to hold the organs up.
Here’s a classic view of the of the female pelvic floor seen in many anatomy textbooks:
The view is from the top down with the spine at the back (bottom) of the image, the pubic bone in the front (top) and all the organs have been removed.
You can see how the multiple muscles of the pelvic floor form a sling and that sling perforated by three tubes, at the top is the urethra, which carries urine from the bladder to the outside, the middle tube is the vagina, and the tube underneath is the rectum.
Now imagine a baby’s head, 10 centimeters in diameter, passing through this sling. It’s obvious that the fetal head is going to dramatically stretch, distort and possibly tear the muscles that surround the vagina. They will literally never be the same again. Where once the space between the muscles of the pelvic floor was only large enough to accommodate three relatively small tubes, now that space has been stretched tremendously.
Keep in mind that we are talking about internal muscles, not the tears in the vagina that occur externally (1st, 2nd, 3rd and 4th degree tears). External tears produce visible external damage. It’s not difficult to understand that a 3rd degree tear (a tear through the sphincter muscle surrounding the anus, which is locate below the level of the pelvic floor) makes continence of flatus (gas) and stool impossible. The anal sphincter is under voluntary control, but if it is torn, the anus cannot be closed to the prevent the release of the contents of the rectum. Stitch the sphincter muscle back together again and continence will be restored.
Injuries to the muscles of the pelvic floor take place at a deeper level, not visible externally, and not accessible to repair. The most common injury to these muscles is stretching and kegel exercises are designed to strengthen the muscles and thereby tighten them. But the injuries can be more severe than stretching. The muscles themselves can be torn away from the pelvic bones.
Midwife and co-author of the new research into psychological consequences of traumatic vaginal birth Elizabeth Skinner spent two years gathering and analysing the experiences of women who have suffered traumatic vaginal births.
“Women who have sustained vaginal birth trauma often have avulsion of the levator ani muscle. This is a disconnection of that muscle from the pelvic bone resulting in prolapsed organs. Women just put up with this “hidden injury” as they are too embarrassed to discuss symptoms with clinicians who frequently do not believe them,” Skinner says.
No amount of kegel exercises can repair pelvic muscles that are torn. When these muscles are torn, the pelvic organs can slip through the middle of the pelvic floor. This is known as prolapse. When a pelvic organ like the bladder prolapses, it distorts the relationship between the sphincter that controls release of urine from the bladder into the urethra. Although the sphincter itself has not been damaged, it nonetheless prevents the woman from “holding” urine. It works well enough that urine doesn’t constantly dribble out of the urethra, but when the intra-abdominal pressure is dramatically increased as occurs during coughing and sneezing, urine squirts out (stress urinary incontinence).
The damage may not be immediately apparent. It may not appear until menopause when ligaments are weakened by the lack of estrogen and the pelvic organs begin to drop between the muscles. A woman who has had no problem for 20+ years after the births of her children may gradually develop uterine prolapse and/or incontinence as she enters menopause.
How often does damage to the pelvic floor occur?
Professor of Obstetrics & Gynaecology, at the University of Sydney’s Medical School Hans Peter Dietz says that damage from vaginal birth is much more widespread than generally assumed.
“Only about 25 per cent of women get a non-traumatic normal vaginal delivery that did not do serious damage to their pelvic floor or their anal sphincter’, says Professor Dietz. ‘And this is on first time mothers. If we did this kind of analysis on women who try for a VBAC (vaginal birth after Caesarean) it would probably be as few as 10 to 15 per cent.”
In other words, up to 75% of women who have a vaginal birth will end up with some permanent damage to the muscles. The likelihood of damage rises dramatically with the use of forceps for obvious reasons. Putting forceps into the vagina and around the baby’s head creates a larger diameter than the baby’s head alone.
In our efforts to reduce the C-section rate, we’ve made the problem worse.
The policy to reduce caesarean births has lead to an increase in the use of forceps during vaginal deliveries and a tolerance for longer periods of pushing during the second stage of labour, both of which increase the risks to the mother and baby.
“The forceps rate has doubled in NSW over the last 10 years. At some hospitals quadrupled,” says the University of Sydney’s Professor Dietz. ‘That means much, much more damage is done than ten years ago — in some instances twice as much. This is largely a result of the attempt to reduce the caesarean births rate.”
One way to completely prevent damage to the pelvic floor is to have a C-section on maternal request.
Elizabeth Skinner and Professor Dietz are not against vaginal births; in some cases a vaginal birth is the best option. They also note that a caesarean section is major abdominal surgery and carries its own risks.
However women who have big babies, are short in stature, have Asian heritage, and have a family history of difficult births should be informed of their greater risk of trauma if they have a vaginal birth. And all women should be given the choice to make an informed decision for themselves.
Urinary and fecal incontinence, uterine prolapse and painful sex are not trivial problems. They can be life altering and the are the entirely normal consequences of completely normal vaginal birth. It’s hardly surprising that many women want to avoid them and it’s deeply unfortunate that in a society where vaginal birth is valued more than C-sections, no one warns women that they can occur.
