Childbirth injury risks

[BackInTime]

A discussion among friends about our childbirth experiences has made me think that not enough information is given to women about the possibility of injuries and long term problems as a result of a vaginal delivery. Almost all of us have ongoing incontinence, some had bad tears and one has had a prolapse needing surgery. These things are impacting women’s lives years after giving birth. It seems to be a hidden problem with many women suffering in silence.

AIBU to think that women need to be more informed about risks of a vaginal delivery especially in situations where there’s a high risk of injury like with a big baby?

There’s a Cochrane review showing that no, positioning /excercises does not work to move the position of a baby.

Your friends baby will have moved of it’s own accord, regardless of what she did.

I think there is a lack of information because these subjects, especially anything involving gynaecology, are taboo. Before I had children, I had no idea how prevalent birth injuries, incontinence and prolapse are. They were something that happened to little old ladies. Then I had kids and found out that a good 30% of my friends have issues with prolapse and incontinence post kids. Have my mum or aunts ever spoken about this? No. Had I ever read magazine articles about it? No. It rarely gets a mention in the papers. It’s just not spoken about and instead, we’re expected to suffer in embarrassed silence

As for researching prior to birth, what does this actually achieve unless you decide on an elective section? I had two relatively straightforward, if long, births. No amount of research would have prevented my prolapse tbh (big headed baby, shit ligaments). What would have helped would have been a proper gynae exam at 6 weeks post birth so that I would have known I had a mild/moderate prolapse and could have taken appropriate measures to prevent it getting worse. Instead, I did a load of stuff I really shouldn’t have (heavy lifting) and ended up needing surgery. A small increase in postnatal care could go a long way in preventing major long term problems.

In france, ten free individual session of postnatal physio with a midwife come as standard. No reason that shouldn't happen in the UK.

As a HCP working in this field, I think the main problem is actually the after care- things like lack of pelvic floor physiotherapy- women are told to "do pelvic floor exercises" but that's about it. If done properly and early enough, this is often enough to prevent incontinence- obviously if you have a larger tear or have other risk factors for pelvic floor weakness (being very overweight or having connective tissue disease, for instance) then it is obviously more complicated.

In addition, I would say women having large babies or other risk factors are usually well counselled about risks of vaginal birth vs risks of caesarean section. It's the women who don't really have predictable risk factors who perhaps don't fully appreciate the risks- and there is a fine balance as to how that is done.

We are trying to improve our pelvic floor physiotherapy services and have recruited specialist physio's to work between maternity and the continence service. But it would be expensive to role this out so that every woman has 6 weeks of specialist physiotherapy postnatally as they do in France- and we'd need more specialists in this area. I would be all for it from a clinical perspective and believe it may pay for itself in the long run- but the initial investment would be problematic in the current financial climate.

I don’t know it works in other areas but at my trust we ‘score’ peoples risk of pelvic floor issues after birth. So long pushing stage, big baby, perineal trauma, instrumental delivery etc. All score. If a woman has less than 2 it’s normal pelvic floor advice. 2-5 and it’s a postnatal appointment with a physiotherapist. More than 5 and it’s ongoing physiotherapy and consultant follow up.

It's really a question of financial priorities jacks as you suggest. If we have money for Trident, we have money for women's health, plus I believe as you say the French system pays for itself in the long run through reduced prolapse etc. care later in life.

That’s good, but why are women allowed to push for prolonged periods? Why isn’t foetal size and positioning assessed at /prior to onset? Why are forceps still being used at all when in many European countries they’re seen as a relic?

@jacks11 I had 2 large babies (12lb and 11lb). I received absolutely no counselling regarding the risks of vaginal v section birth. No one ever mentioned the possibility of a section to me in my first pregnancy and no one seemed to take my concerns into account at all. I repeatedly asked for a growth scan as I got close to my due date, but was refused. I knew I hadn’t a massive bump, but my midwife kept telling me I was within normal ranges. The only thing I wasn’t granted was a GTT, which came back negative. I had a horrendous first birth as a result of his size. When my midwife phoned me up in hospital and I told her the weight, she said “bloody hell, where we’re you hiding him?”. Nowhere. He was in plain sight.

I think many of my problems came from this one midwife. She was the only one I saw throughout my first pregnancy. I didn’t meet anyone else to discuss my pregnancy as and 20 weeks and the GTT, but the people doing those scans and tests we’re there to administer the tests and didn’t speak to me about anything else. They referred me back to my midwife to discuss results. I did actually complain about my midwife and she disappeared soon after.

@Bowlofbabelfish Apologies if I'm being a bit dim (highly possible) but I'm not sure I understand your competing evolutionary pressures point.

I know that humans evolved narrower pelvises than would be ideal for child birth to facilitate walking upright, but surely there is a point where a slight mutation in one generation would mean that woman's pelvis becomes so narrow that it would prevent successful vb? These women presumably wouldn't be able to continue their genetic line if left completely to nature even if the narrower pelvis made you somehow better at walking as they and their offspring would not make it through childbirth. Modern medicine would obviously step in during these cases now to hopefully save mother and child but wouldn't this increase the likelihood that the mutation that led to the narrow pelvis would be replicated in future child bearing women and therefore reduce the likelihood of a successful vb?

I'm not saying you're wrong btw, just genuinely trying to understand the flaw in my current thinking. I'm definitely not an expert on evolution

@Bowlofbabelfish

Women can be pushing for a long time and it still be considered normal. Up to 2 hours is normal for a first baby, 1 hour for second onwards. Any longer than that and unless delivery is imminent something should be done.

bumpity there are multiple pressures acting on us at any one time. There is considerable variation in the population. If our woman had a narrow pelvis and died in childbirth, this kills her, but it doesn’t stop the overall pressure to have a narrower pelvis which comes from the fact it’s more efficient. Women with pelvises JUST narrow enough to get away with it will survive and thus that hypoethical gene will continue and still work in the population. The pressure is still there.

Of course it’s not as simple as one gene one trait for most things. If you have a single gene trait like say sickle cell anaemia which is massively harmful if you have two faulty copies you can still have a strong pressure to keep the gene because one copy is beneficial if where you live is riddled with malaria.

So let’s say our narrow pelvis gene is like that - one copy, you get away with it and you’re able to birth, just and are more efficient walking. Two copies just takes the pelvis into too narrow and you die.
The gene persists, because there is a beneficial selection pressure on it even though two copies will kill you , and the women who hold two copies well that’s just bad luck for them.

It may be a similar thing for cystic fibrosis- if you’re a carrier you’re not badly affected. If you have two copies, you are and previously you’d have died very young. So why does it persist? Well maybe there is or there was very recently a benefit to being a carrier- there’s a theory that carriers survived the black death more, and we are just now seeing historical echoes of that.

@Bowlofbabelfish Thank you for taking the time to write your response. I think I understand better now why my assumptions were a bit simplistic. Presumably in this day and age though there isn't a massive advantage to walking better in terms of survival rates so if modern medicine didn't intervene the carriers of the double narrow pelvis gene would die in childbirth meaning at a population level the number of women carrying the narrow pelvis gene would be less so overall we would be better at giving birth? Based on what you say though I can see how the problem wouldn't be eliminated completely, but surely it would lessen the prevelance?

The scheme in your area sounds brilliant, catching. Pretty sure there is nothing similar here as I haven’t heard of any of my friends being referred for physio and we’ve had a range of birth experiences. The approach has been to channel all resources into care during delivery (which is excellent) and then abandon you to your fate postnatally. A good example was after my first birth- I had diamorphine and a fairly big second degree tear but was given no advice on the need to use stool softeners and avoid constipation. Pretty certain that the resulting horrific constipation contributed to my prolapse

As far as I know, you're not supposed to just lump the incontinence issue. GP, referral to physio, get it sorted out is the better route surely?

I can't imagine just blithely accepting I should now piss / shit myself all the time just because I've had a baby. Make some noise imo, change GP if yours is crap.

And when I did finally get a physio referral prior to my surgery, the physio service sent me a load of bumpf about where to buy my incontintence equipment (I don’t have any problems with incontinence). It was aimed at elderly women with mobility issues and drove home to me that it was a one size fits all service that had nothing to do with postnatal women. My surgeon confirmed it would basically involve sitting round in a circle for a chat about pelvic floor exercises and was completely inadequate. I had to go private so that I could get the proper internal exam that I needed.

See above, pandarific. My GP was great, the service on offer was not.

Could the knowledgeable posters please make some suggestions of where people who would like some accurate information on birth injury and risk of, should go to read up please?

19 weeks pregnant, low risk for everything so far, am opting for if possible pool first, but more importantly mobile epidural (which my hospital does do).

pandarific the RCOG website is very useful. Start with the information that 90% of first deliveries result in tearing and work from there

@pandaridic

Look up Nice guidelines for antenatal, intranatal and postnatal care, they then link to the evidence behind the guidelines. Cochrane reviews are another good source of high quality research studies.

Most mobile epidurals are not really mobile as in you can walk around btw, it means mobile as in you can still feel pressure to be able to push. You couldn’t have an epidural AND be in the pool, it’s one or the other. An epidural would also mean you would be recommend to have a CTG to continually monitor the baby’s heart rate as epidurals can cause bradycardia (the heart rate dropping too low). The CTG can also restrict your mobility depending on wether or not your hospital has wireless ones and even if they do, depending on how well they record.

Thank you @catchingbabies, I specifically asked the midwife if they did mobile epidurals at my hospital, and described it as in, you can walk around after the mandatory monitoring period, so unless she's lying they should have them. I'll check again.

I know you can't have both a pool and epidural at the same time, I meant start off in the pool and then epidural, which I learned on here is a possibility if you're very lucky, and midwife didn't say no when I asked, just said would obvs prioritise epidural as wouldn't want to spend too long in the pool and then miss the window for the epidural.

It’s possible bumpity and it’s actually a question that’s argued over quite a lot in genetics circles - basically what is the effect of our current living environment on our genetics?

This stuff doesn’t happen fast, is one thing to remember - if you want a gene to spread to full oenetrance in a population you have to do something seriously drastic. Myxomatosis resistance in bunnies, andromeda strain level stuff. If it’s a more subtle thing it might take millennia to get rid of.

I also specifically asked about the monitoring and having to be on your back after the mobile epidural as I've read bad things on here re: being stuck static after epidural which I definitely don't want, and she said that's not the case unless they pick up a problem.

It's BSUH in brighton if that helps, from what I've read online they seem to be quite well thought of?

You don’t have to be on your back for the monitoring but if it’s not wireless you need to be close to the machine. If wireless it doesn’t always pick up well and you need to convert to wired.

And remember you don’t HAVE to do anything in fact, you are well within your rights to say no.

Bumpitybumper and Babelfish, apparently if we helped no women in labour at all and left it all to evolution our pelvises would look more like apes pelvises do after as little as 10 generations, I read somewhere.

It makes me annoyed when people talk about how our bodies have evolved to do things, the mechanism to decide whether you are an evolutionary hit or miss hasn't been applicable to Homo sapiens since we evolved social skills and language I reckon.