Better care for mothers with birth injuries: what needs to be done?
1. More data and more research
The prevalence of medium-term and long-term symptoms associated with birth injuries is largely unknown; long-term data on mothers’ health following birth is not routinely collected and systematically analysed. While individual researchers continue to try to work out the prevalence of long-term effects, and find out what the contributing factors are, they are limited to local and regional data sets, and often to self-selecting surveys.
What we don’t have is a single, national long-term data-set tracking mothers’ experiences from birth through to menopause and beyond. There’s no data set to give us definitive answers to questions such as: how many mothers are still finding sex painful three, five, 10 or 20 years after they gave birth? How many mothers are suffering from birth-related urinary or faecal incontinence, and how are they being cared for? How does birth mode impact on women’s long-term health – if at all? (For example, this Cochrane Review of 2012 concluded: ‘The review of trials looking at attempted instrumental delivery in theatre versus immediate caesarean section for anticipated difficult births identified no trials to help with making this decision. Further research is clearly needed.')
Another option is to approach the National Institute for Health Research with specific requests for research into aspects of birth injuries and long-term effects.
A current list of all national NHS England data sets can be found here.I would like to see birth injuries followed for the lifetime of the injury and included in the statistics. Right now all I am seeing is items like c-section rate. Data is absolutely critical – it’s what drives our ability to hold people to account and to improve practice.
2. Proactive care
- Antenatal classes and information should include material about the signs and symptoms of perineal and vaginal wounds, to help women get a sense of what's 'normal' post-birth, what's not, and how to seek help. This is particularly important for first-time mothers, who are more at risk of perineal and vaginal trauma.
- Women who have had perineal or vaginal trauma during birth should have a plan of care prepared as they leave hospital, to ensure that their midwife/GP knows what degree of perineal trauma the woman sustained.
- Postnatal care should be tailored to each woman’s individual needs. This could include normal, intermediate and high-risk postnatal care pathways.
- All postnatal contacts following the woman’s discharge from hospital should include an assessment of their perineal healing.
- Women should be advised about pain relief and how to care for their perineal trauma, including importance of hygiene, changing their sanitary pads frequently and washing their hands each time they change their pads or go to the toilet.
- If a woman continues to report pain or offensive odours from her perineal wound or vaginal loss, they should receive a thorough perineal examination, as soon as possible, performed by a midwife or GP with the appropriate competencies. Some women may require an internal examination in order to identify possible problems, the need for which should be explained and conducted sensitively, ensuring that the woman is as comfortable as possible.
- Where appropriate (ie in the most serious cases of perineal wound breakdown), a multi-disciplinary care review may be required to ensure the woman has the best possible care.
- Midwives on the postnatal wards or visiting women in the community should ask each woman at each contact about the amount of perineal pain she's experiencing (for example, using a 1-10 scale) and use this as an escalation prom
3. Recognise that 'postnatal' can mean 'long-term', or even 'lifelong'
We need to reframe our cultural and medical understanding of what 'the postnatal period' means; symptoms and associated health effects do not end at 6-8 weeks post-partum. Clinicians need to be on the lookout for birth-related conditions and symptoms for months or even years after a birth, and should be proactively asking women about their recovery, health and wellbeing. According to our survey, most women do not seek medical help – perhaps partly because they 'expect' to experience health problems, such as stress urinary incontinence, after giving birth. They need to be encouraged to speak up about their health concerns and they must feel heard, and receive appropriate care, when they do.