'Nobody wants to acknowledge you can get PTSD after birth': Birth trauma is more common than you may think
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She was a woman with a thriving business, pregnant with her second child and – on the third visit to her midwife – she started sobbing and crying.
“She’d been experiencing urinary and faecal leaking since the birth of her first child two years earlier. It was affecting all aspects of her life. She cried and cried – she was miserable,” recalls Deirdre Daly, assistant professor in midwifery at TCD School of Nursing and Midwifery.
Daly was a practising midwife in an outlying clinic of the Rotunda when she met the woman in 2010, and the encounter sparked the MAMMI (Maternal Health and Maternal Morbidity in Ireland) study, a longitudinal, cohort study examining prevalence and risk factors for a range of health issues in more than 3,000 first-time mothers in Ireland.
“It may not be popular to say, but all births carry a level of physical trauma,” says Dr Krysia Lynch, chair of Association for Improvements in the Maternity Services (AIMS Ireland).
Yasmin Ismail, consultant plastic, reconstructive and aesthetic surgeon at the Beacon Hospital says trauma of the perineal and vaginal tissues is experienced by more than 80% of women giving birth – most of these are first-time spontaneous vaginal deliveries.
Yet it’s important to point out that birth-related injuries exist on a continuum from mild to more complex. “Birth is a normal physiological process and women’s bodies are very resilient. Given the right amount of support during labour and in the post-natal period – when rest is vital – the vast majority of women recover from minor injuries within six weeks,” says Lynch.
And of course pretty much every woman feels exhausted, bruised and may have some minor grazes or tears, but what would you expect, asks Lynch, when “physically most women feel like they’ve gone through a marine commando course”.
Birth-related injuries can involve the urethra, labia majora and labia minora, the vagina (internally and externally), the anal tissues and the sphincter. Injuries can include tears, scarring and fistulisation – where an abnormal connection/hole occurs between two organs. “The vagina and sphincter tend to be involved in more serious injuries,” says Ismail.
The MAMMI study found 51% of women were experiencing urinary incontinence three months after the birth of their first child, while just over 41% continued to suffer a year postpartum. Faecal incontinence affected four per cent of study participants three months postpartum, while over two per cent were suffering a year after their first child’s birth.
Lynch points to the term ‘obstetric violence’, referring to the performance of unnecessary medical interventions that can result in physical trauma and injury.
“Medical staff try to get it right but they don’t always,” she says.
Explaining that during labour a woman’s perineum needs to gently expand, release and stretch, Lynch says a mother who’s had a very fast birth can sometimes have a perineal injury as a result of things progressing too quickly. “It’s more common in women who are induced,” she says, adding that Ireland’s induction rates have increased during the pandemic. “Average rates are around 38% and in some units, first-time mother rates are 45%.”
Lynch says our maternity services are “fond of” short second stage of labour – often limited to an hour – where nature might prefer longer. “Women are obliged to push beyond what their body’s telling them to do, which for many first-time mothers is quite traumatic.”
However, if the birth is taking a long time and there’s a lot of forceful pushing down over an extended period, it can be hard for the pelvic floor to maintain elasticity. “Post-birth, women can suffer from issues associated with a lax pelvic floor. There can be some level of incontinence – urinary’s more common but there can be double incontinence, usually occurring when the woman sneezes or coughs.”
While episiotomy is sometimes “absolutely essential” if the baby’s getting into distress and needs to be born quickly – or if the midwife sees the procedure will better manage a potentially bad tear – Lynch says it’s quite a serious intervention. “It involves cutting through layers of tissue that will need stitching, so the woman has to cope with quite significant scarring while dealing with a newborn.”
For a variety of reasons, women don’t talk about the physical trauma effects that continue to plague them post-birth. “It’s very personal. They’re talking about their perineum, vagina – intimate parts of themselves. Very often they don’t want to admit these difficulties,” says Lynch, adding that when women do confide, it’s often in older female relatives, for example, their mother. “They often get told, with best possible intentions, ‘ah well, you’ve just had a baby – you have to expect this’.
There’s not enough education that it’s not normal to have leaking of urine or faecal matter, pain with intercourse or feel excessively tired – just under 10% of women get pregnancy-induced hypothyroidism where they become excessively tired.”
Daly says in Ireland a lot of information is collected and reported during pregnancy, labour and birth – but we stop collecting and reporting national information on women’s health after the birth. “In the post-natal period, the focus moves to the baby. This happens throughout the world – women’s health, post-partum, is a neglected area.”
The MAMMI study recruited 3,047 women from three maternity hospitals in Ireland. One of the largest prospective maternal health studies globally, information is gathered at two time points during pregnancy, and at three, six, nine and 12 months post-partum. The study examines health issues including urinary and anal incontinence, pelvic girdle pain, mental and sexual health problems and readmission to emergency rooms/hospital.
“One thing that struck us most that started emerging early on was the number of women who were experiencing one or several health problems at different time points,” says Daly.
And women weren’t being asked about these problems by health professionals. Well over 70% weren’t asked about urinary or faecal incontinence by their GP, while approximately 60% reported their midwife/public health nurse didn’t enquire. And while more than 18% of women had sexual health problems a year post-partum, well over eight in 10 said they weren’t asked about this by either GP or midwife/PHN. “
Women were suffering in silence. And while these problems mightn’t kill you, they do leave you feeling miserable and affect every aspect of your life,” says Daly.
Lynch points out that in France the maternity package includes post-natal access to a woman’s physiotherapist. “It’s to ensure the pelvic floor health is as it should be. It doesn’t happen here unless you pay for it.” She recommends women – whether experiencing continence issues or not – see a woman’s physiotherapist for assessment of their pelvic floor and general abdominal health. “The physio will be able to feel exactly what’s going on and will give the woman exercises to build up strength and tone again.”
More complex injuries are best managed by referral to colorectal and uro-gynaecology specialists. Colorectal specialty care can be obtained under the public health service, but there are huge waiting lists, which Lynch says Covid-19 closures have further impacted. “Another issue is some of the newer approaches to treatment may not be available publicly. People chose to go private to minimise the wait and to increase quality of life in early parenting.”
Asymmetry, simple tears and uncomfortable scarring are the kinds of problems that Yasmin Ismail commonly sees. “Some patients may have tried non-surgical options – pelvic floor exercises, scar management or even vaginal dilators if they’ve been stitched too tightly. Not all women are appropriate to undergo surgery.”
Physical impacts of these problems vary – from discomfort and being unable to wear underclothes/swimming costume to unease about how it looks to recurrent infections, for example, thrush and cystitis. “There can be an inability to be intimate or have intercourse with their partner for physical or psychological reasons,” says Ismail.
Recovery times post-surgery vary, says Ismail, from two to four weeks for symmetrisation or resolving a simple tear to several months if scar revision is done – using a plastic surgery technique to move tissue around for “a better functional result that restores the anatomy aesthetically”.
The woman who 10 years ago sparked the awareness that led to the MAMMI study got the appropriate help, confirms Daly. “By the end of her pregnancy, the issues were resolving and she was so chuffed.”
What Daly wants women to know is that injuries acquired during birth can impact post-natally but they should never be seen as natural or as something the woman puts up with. “They can be fixed. Don’t let these health issues control you. Take back control. You should be thriving.”
- The MAMMI study has developed a suite of resources pertaining to women’s health after motherhood.
- AIMS Ireland has a peer support group for women who’ve suffered obstetric anal sphincter injury.
- Parent-to-parent voluntary support charity Cuidiú is currently training volunteers in Birth Reflections, which will deal with post-birth trauma. “A physical trauma’s often linked with emotional trauma. Birth Reflections is a safe space where people can share their feelings about the birth experience,” says antenatal teacher and tutor with Cuidiú Mim Moran. To find out more, email mimantutor@gmail.com
In labour with her second child, mum-of-three Nuala Hoey felt an instinctive urge to slow things down. “I asked the midwife if the baby’s head was crowning. She said ‘I want you to push. Push with all your might – keep it coming, keep it coming’.”
Immediately, Nuala heard her body rip. “I can still hear it, as loud as it happened that day. I tore from my vagina into my back passage,” says the 39-year-old Navan woman, whose three children – two daughters and a son – are aged 12, 10 and five.
The birth had lasted just two hours and 38 minutes, and in the hospital she was diagnosed with third-degree tear and brought to theatre for surgery. “I wouldn’t say the surgery helped,” says Nuala, who is doubly incontinent. Referred to the hospital physio, Nuala was told she had great pelvic tone before being discharged.
But she couldn’t understand why her body was failing her post-partum. “The darkest moment was when I was breastfeeding my baby and without warning I faecally soiled myself. I felt bleak, totally helpless.”
Nuala returned to her GP to seek physiotherapy and to see a pelvic health specialist. She then saw a colorectal consultant, who – 14 months after the birth – confirmed she’d had a fourth-degree tear.
Just last year, Nuala was diagnosed with PTSD after years of seeking therapy and mental health support. “Nobody wants to acknowledge you can get PTSD after birth. You’re made to believe it’s depression, part of life after motherhood, but it’s not – to have nightmares, panic attacks, adrenalin levels too high for you to simmer down.”
When it comes to this kind of injury, Nuala feels people don’t want to know. “They don’t want to talk about tearing your vagina, having problems holding poo in, that you can’t go grocery shopping because you’re afraid of soiling yourself. I’ve had people say ‘isn’t it time you got over this’ or ‘just be glad the baby’s OK’ – which said to me I didn’t matter.”
The PTSD diagnosis brought a sense of validation. “It was a stepping stone in my mental health recovery. I’m in a good place now. It took a lot of talking with my husband, with my children, to get to this point. I’ve had counselling.”
While the tear healed well in time, options that might’ve been possible for Nuala included stoma care and sphincteroplasty once she’d completed her family. She had her third child, a son, at home. “It was important to me to have a home birth so my children would know that physiologically birth can be normal, it’s not something to be feared. I had a great birth – but with a third-degree tear. It didn’t even register because the birth and midwifery support I received at home was just fantastic.”
Nuala has discussed surgery for a magnetic sphincter with a colorectal surgeon. “I’m told my muscular tone’s quite good, so no surgical options are advised at the moment. However, I’m prone to recurrent infections – UTI, bacterial vaginosis, cystitis – as a result of the incontinence.”
