Time for a rethink in the choices presented to mothers-to-be

The assumption that vaginal delivery is always to be preferred must end and a more patient centred approach adopted, writes Doireann O’Mahony.

Time for a rethink in the choices presented to mothers-to-be

We need to end the silence around the devastating impact vaginal births can have on women and rethink the assumption that this type of delivery is the preferred option.

The Royal College of Obstetricians and Gynaecologists’ (RCOG) own figures show fourth-degree tears — the most severe type, which involve the perineal muscle, anal sphincter, and/or rectum being damaged — increased three-fold in the 10 years to 2012, and are now at an all-time high.

As many as 10% of mothers who give birth through the birth canal will develop some form of anal incontinence.

That’s about 67,000 women each year in the UK alone leaving the labour ward with a new baby and a devastating life-long injury.

Judging by the RCOG’s figures for the UK, and assuming more than 60,000 women give birth to live babies in Ireland each year, some 10%, or 6,000 mothers will have impaired rectal continence here.

Not all of them will be permanent but a significant percentage will not regain continence even with corrective surgery.

The impact of such an injury on a young woman is catastrophic. Her entire life is controlled by faecal incontinence.

She may experience unconscious soiling, finding after the event that an accident had happened.

More commonly, she may find that she has no control over wind and such a degree of urgency that she has only minutes (in some cases only a few seconds) to reach a bathroom before a major disaster.

Many such women cannot leave the house unless they can be sure of finding a safe refuge in the event of an urgent need.

Simple daily tasks such as taking children to and from school or visiting the supermarket require major advance planning.

Socialising for these women is not an option. They must take great care with their diet and sometimes even with such care accidents will happen.

Athletic pursuits such as running, tennis, horse-riding or even yoga will usually no longer be possible. For the professional woman, this injury will often signal the end of her career.

Sharing the experience with another is so shameful that for many it is impossible.

The woman will fear that her husband will no longer wish to be intimate with her while there is a threat of incontinence.

She fears such shame because of her symptoms that she cannot share her tragedy with close friends.

The shame also prevents her discussing the incontinence with her doctor. Many wait for years before plucking up sufficient courage to ask for help.

Why is this happening? The majority of these injuries follow operative vaginal delivery with forceps.

This is a highly skilled procedure which requires manual dexterity and precise application of the instrument, skills that appear to be in diminishing supply.

Junior doctors nowadays spend less time in the labour ward (and other frontline areas such as operating theatres, emergency departments), areas where manual dexterity and hand-eye co-ordination have to be learned by experience.

You cannot teach carpentry from a textbook.

This should come as no surprise to anyone familiar with the European Working Time Directive and the effect this has had on junior doctors’ hours.

Understandably they expect to be trained in the same number of years as their predecessors of five or six decades ago. But this is clearly impossible.

At the same time there has been an irrational pressure from ‘authority’ to reduce the number of Caesarean sections on the mistaken assumption that the operation is too dangerous and too expensive.

Too dangerous for whom? Certainly not for the baby.

As to risk to the mother, the question needs to be asked: What risk of elective C-section could outweigh the known risk, in any particular case of vaginal delivery?

As to the cost, it depends when you stop counting. If at the time the mother goes home with her baby, then yes, it is more expensive.

But if you wait until the end of her life, she will have required much less maintenance in the form of prolapse, urinary incontinence, than the woman who gave birth by a vaginal instrumental delivery.

And what about consent? Doctors are reluctant to explain the risks both to mother and baby of operative vaginal delivery, while forever stressing the dangers of the relatively safe and secure option of elective C-section.

They insist on written consent for C-section (no matter the extent to which the mother may be under the influence of repeated doses of opiates) whereas there is seldom even oral consent for operative vaginal delivery, and very rarely a written record.

It is time for a rethink.

We need to make sure those who influence decisions learn from the experience of these grievous injuries and approach difficult birth with an open mind.

The assumption that a vaginal delivery is always to be preferred must surely now be abandoned.

There should be a patient-centred approach in which the mother feels entitled to make the doctor take into account her own values.

There can then be an assessment of comparative merits of giving birth vaginally and by C-section, whatever medical opinion may be, alongside the evaluation of the risks to mother and baby.

Doireann O’Mahony is a barrister who is taking part in an event today in Kings Inns, Dublin, entitled ‘Exit Wounds’ Maternal Urological Injuries and Anal Sphincter Injuries in Childbirth’.

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