BBC’s Victoria Derbyshire programme has broken the taboo. Severe perineal tears were the main item last week.
You can read a summary article here or watch the programme here.
unrepaired tears
Severe perineal tears
Severe perineal tears are highly linked to anal incontinence following childbirth. The Royal College of Obstetricians and Gynaecologists has reviewed its patient’s leaflet about these tears.
A third – or fourth – degree tear during birth June 2015
Even though this is an improvement on the previous version, the leaflet does not give a rate of anal incontinence following severe tears. It does say:
“To start with, some women feel that they pass wind more easily or need to rush to the toilet to open their bowels. Most women make a good recovery, particularly if the tear is recognised and repaired at the time: 6–8 in 10 women will have no symptoms a year after birth.”
It is still a step away from mentioning women who actually leak stools. It is a horrifying experience.
Today I simply want to do a little maths exercise to put numbers into context using the number of births in England and Wales in 2013.
There were 698, 512 live births in England and Wales in 2013. The RCOG leaflet puts the overall rate of third and fourth degree tears at 3%. So we’re looking at 20,956 women who suffered these tears. The leaflet then indirectly explains that 2 to 4 out of 10 injured women still have symptoms one year after giving birth.
This means that between 4,192 and 8,383 women still had symptoms one year after birth. Because these statistics are only for England and Wales, the number for the UK (including Scotland and Northern Ireland) will be higher. Also these statistics are only for one year. Similar numbers of women suffer from these injuries year on year.
Book review: What to expect when you’re expecting
Title: What to expect when you’re expecting New 4th edition
Authors: Heidi Murkoff, Sharon Mazel
Publisher: Simon & Schuster 2009
Ratings
Risks associated with instrumental delivery: 1/5
Faecal incontinence: 2.5/5
Pelvic organ prolapse: 1/5
Perineal tears: 2.5/5
Overall rating: 1.75/5 I find this book puzzling. It seems to cover most topics but in the end fails to give important information (risks associated with instrumental deliveries, pelvic organ prolapse). It also seems to normalise faecal incontinence after birth and in my view doesn’t give the correct advice as to what to do if this happens to you. Not a good book.
Brenda Smallegan who recommends the book at the beginning says: “Any topic you can think of can be looked up right away.”
I thought of “pelvic organ prolapse” and “risks associated with instrumental delivery”. I could find neither of these. As Nick Davies said: ” ‘The earth is flat.’ Anybody anywhere until somebody checked.”
Let’s have a look at other topics.
Hurray! There is a paragraph on faecal incontinence. Ah, but hold on… It doesn’t quite say what I was expecting it to say. Umm…
My view is that this answer about faecal incontinence normalises the problem (“In most cases, the problem takes care of itself”). This is not good advice.
It does say that “the muscles and nerves in the pelvic area are stretched and sometimes damaged, which can make it difficult for you to control how and when waste (and wind) leaves your body”. So what are the risk factors? Why are you not mentioning them?
If you experience faecal incontinence, get checked. The extend of the damage will be assessed and treatment given accordingly. It is also the view of my women’s health physio. Faecal incontinence after birth can happen but it is not “normal”. Get help.
The box “Help for leaks that won’t let up” seems to suggest trying sorting things out on your own first. Starting pelvic floor exercises is imperative but again I wouldn’t advise waiting to get medical advice and guidance. Both urinary and faecal incontinence have such an impact on your daily life and confidence, I think it is better to get support and not suffer on your own.
I also need to say I don’t like the underlying casual tone of the writing, for example “but you probably didn’t count on cleaning up after yourself”, “tried the do-it-yourself trick”, “Kegel-ing until you’re blue in the face”.
There is unfortunately no mention of instrumental deliveries or other risk factors.
Finally and importantly I was expecting 3d and 4th degree tears (scroll down to “More complicated tears”) to be mentioned. If the tear is seen and repaired at the time, you stand a chance of avoiding the worst. According to this article, women who have a primary repair (repair done straight after delivery) still have a 59% chance of experiencing faecal incontinence.
Now let’s see what is said about perineal tears.
This is informative but again only to a degree. Whereas in other sections mentioning both urinary and faecal incontinence (see below) is deemed important, it does not seem to be here: “[Severe tears] increase not only your postpartum recovery time, but your risk of incontinence, as well as other pelvic floor problems”. Strange. You have to join the dots together.
It also again fails to mention risk factors, including instrumental deliveries.
The eventuality of a tear being left unrepaired is not mentioned here but under postpartum haemorrhage. Why not in this section too?
The more straightforward information about tears is to be found in the article about episiotomies. They do give good advice on trying to avoid an episiotomy.
Let’s turn to risks associated with instrumental deliveries (see above).
Forceps
“But if your doctor does decide to use forceps, rest assured; they are as safe as a caesarean or vacuum extraction when used correctly by an experienced practitioner” Safe for whom? The baby? The mother? Both? And safe in what way? I think the risks of a C-section or an instrumental delivery are different so I’m not sure what “safe” means here.
I suppose the risks of severe tears are mentioned in the section about episiotomies. But again you have to put 2 and 2 together: an episiotomy puts you at higher risk of a severe tear so if you need an episiotomy with forceps, you are therefore at higher risk of a severe tear. They don’t explain that forceps do more damage to the pudendal nerve and that you can be faecal incontinent after forceps without a severe tear.
No possible long term consequences are mentioned.
Vacuum extraction
“offers a good alternative to both forceps and caesarean under the right circumstances” Does this imply forceps and caesareans carry greater risks than ventouse deliveries? What are the risks?
They mention less trauma to the vagina and a lesser need for anaesthetics. They don’t mention tears or possible urinary and/or faecal incontinence afterwards.
Sound advice: “Before you go into labour, ask your doctor or midwife any questions you have about the possible use of vacuum extraction (or forceps). The more you know, the better prepared you’ll be for anything that comes your way during childbirth.” Why can’t the book itself be more specific about the risks? Or at least give us a list of clear questions to ask the midwife?
The advice on pelvic floor exercises is good and mentions trying to prevent both urinary and faecal incontinence.
However I could not find “pelvic organ prolapse”. It is puzzling as a clear definition of pelvic floor muscles and their role is given: “They’re the muscles that support your uterus, bladder and bowels”. They just fall short of naming the condition and therefore explaining the link between childbirth and prolapse.
A final note on epidurals.
I really don’t think this advice is sound.
Have you bought “What to expect when you’re expecting”? Why not leave a comment here? Or write a review on Amazon?
Book review: Pregnancy the beginner’s guide
Title: Pregnancy the beginner’s guide
Authors: Shaoni Bhattacharya, Claire Cross, Elinor Duffy, Kate Ling and Susanna Marriott
Publisher: DK 2014
Ratings
Risks associated with instrumental delivery: 0/5
Faecal incontinence: 0/5
Pelvic organ prolapse: 0/5
Perineal tears: 1/5
Overall rating: 0.25/5 – This is a falsely reassuring book about childbirth. I do not recommend buying it.
Not a good start. The paragraph dedicated to forceps does not list any risks to the mother.
Worse, it also gives inaccurate and falsely reassuring information: “Don’t worry, everything will be repaired and will heal.” Everything will heal but unfortunately sometimes tears are not repaired. The Royal College of Obstetricians and Gynaecologists do allude to this problem in their leaflet on severe tears.
Click to access a-third-or-fourth-degree-tear-during-childbirth.pdf
It reads: “Most women make a good recovery, particularly if the tear is recognised and repaired at the time.” This implies that not all tears are repaired. I wish the RCOG explained why and also explained what sort of “recovery” women with unrepaired tears are expected to make. This will probably be the subject of another post.
“Can I avoid an assisted delivery? Unfortunately the short answer is no”. I’m not certain this is right. I have heard of some deliveries where women are offered a choice between forceps and a c-section.
They do mention trying to reduce the likelihood of an assisted delivery. They simply forget to mention one important factor: epidurals. Epidurals can slow down labour and therefore put you at higher risk of needing an instrumental delivery. The book sort of mentions it but not clearly enough in my view. See below.
Pelvic organ prolapse is not mentioned. They include urinary and stress incontinence but nothing else. They also fail to explain that in severe cases urinary incontinence following childbirth can be permanent. Women suffering from this may have surgery for it but only after they have completed their family.
I find the following paragraph and diagram absolutely extraordinary!
The diagram clearly shows that the pelvic floor sags just after delivery. However the arrows only point towards the bladder and the paragraph only talks about bladder incontinence. It gives the false impression that your uterus and rectum will miraculously stay in place! This is obviously not true and this is why all women should start pelvic floor exercises as soon as they can after delivery (including women who had a C-section).
Faecal incontinence is not mentioned at all. The irony was to find that they mention pooing during labour. If they feel able to mention pooing during labour, why can’t they talk about leaking stools after birth?
On page 228 you can find a list of possible complications. Faecal incontinence and pelvic organ prolapse are not listed.
Have you bought this book? Why not write a review on Amazon?
Forceps - the follow-on blog 