Link to Telegraph article here:
Six per cent of women in the UK suffer severe birth injuries with their first child, with the physical and emotional fall-out wreaking havoc.
When Karen Evans, now 40, went into labour with her first child she expected pain, of course. She was also prepared for stitches if she tore during delivery. Karen had not been warned, however, about the risk of leaving hospital not just with a new baby but an undetected birth injury so severe it reached into her bowel, requiring two rounds of reconstructive surgery and leaving her anally incontinent for life.
“When I was told I’d probably end up with a colostomy bag I remember thinking having kids didn’t seem like such a good idea after all,” Karen says. “I was so thankful my baby was healthy. But did I really want to pay this high a price to be a parent?”
Karen is one of six per cent of women in the UK who suffer severe birth injuries with their first child, according to the Royal College of Obstetricians and Gynaecologists.
But incidents are likely to be higher as “a third to a half are not detected until women later present with anal incontinence,” says Professor Michael Keighley, a now retired colorectal surgeon and founder of the MASIC charity, which supports women injured giving birth.
His research is echoed by a paper published earlier this year in the American Journal of Obstetrics & Gynaecology, which used data from Europe to look at the long-term effects of such injuries, concluding they double or triple the risk of anal incontinence two decades later. Aged 60, fewer than one in five women was continent, the authors found.
“This is a major social issue affecting a substantial proportion of women having babies – and we just don’t talk about it,” says Keighley. “Using forceps in particular on a first delivery puts the vagina at huge risk.”
Indeed Karen, who is married to David, 42, both physiotherapists in Hampshire, had to be readmitted six days post-delivery when she began passing faeces through her vagina.
“The baby’s heartbeat had slowed during labour so forceps had had to be used to get her out,” Karen recalls. “Suddenly there had been a dreadful wrench and excruciating pain and in the midst of the shock I was wheeled into theatre to stitch up the tear from the forceps.”
Unbeknown to Karen, who hadn’t even been given pain relief, the surgeon had merely tinkered with the surface of a deep wound. As a result it became infected and developed into a rectovaginal fistula, an opening that extended through the perineum – the structure between the vagina and back passage – into the large intestine.
Karen was transferred to a unit with a specialist colorectal team for “long, painful” reconstructive surgery, all the while attempting to continue breastfeeding her new daughter. “I was denied what should have been the happiest time of my life because I hadn’t been examined properly,” Karen says.
Luckily the skill of the surgical team avoided the need for a colostomy, but Karen was diagnosed with severe anxiety and PTSD and had to undergo further surgery three months later – which occurs in up to 30 per cent of primary repairs because of infection and wound breakdown.
Karen’s physical relationship with her husband – who she’d witnessed quietly sobbing at the nurses’ station when the extent of her injury was first revealed – took a year to resume, as did activity as basic as walking the dog. “It made me resent my baby and affected my relationship with her,” Karen admits. “I am ashamed to say that at times I wished I had never become a mother.”
New research undertaken by MASIC shows that a quarter of women who suffered severe injuries during childbirth said they regretted deciding to have a child and a third saw their child as the cause of the injury. A third also had to have further or ongoing surgery while half faced embarrassment due to symptoms of their injury – such as uncontrollable wind or soiling.
Ten years later Karen is still affected, unable to undertake a full range of normal activity, especially sport, and has to take great care about her diet and weight as well as making sure she’s never far from a loo. “I was told my injury was rare, which made me feel like a freak,” she says.
But when MASIC launched in 2017 Karen discovered many other women suffering similarly, including Sarah*.
Sarah, 42, had undergone a “brutal” labour, first enduring her vagina being cut before suction then forceps were introduced to aid her son’s delivery. Sarah’s tear reached the external anal sphincter, classed as third degree compared with Karen’s fourth degree injury, which had also ripped through the internal sphincter. Together they are known as ‘obstetric anal sphincter injury’ or OASI.
Having had an epidural, rendering her unable to feel any sensation, Sarah, who has asked not to be fully identified to protect her son, wasn’t aware of the damage that had been done until she was handed a consent form as she was rushed into theatre for repair. “The form listed potential risks such as bowel incontinence, sexual dysfunction, pelvic prolapse… I was terrified,” Sarah says.
She acknowledges she’s one of the lucky ones because her injury was immediately repaired “so I don’t leak during sex and I’m not acutely incontinent”. Keighley points out that outcomes are “remarkably good” for injuries immediately detected and treated.
But Sarah still developed post-natal depression and PTSD. “I rejected motherhood in the early months,” she says. Eight years later she still has nerve damage, which affects sexual sensation as well as the ability to anticipate when she needs the loo.
“I feel like my body was collateral damage. As long as the baby is fine, you don’t matter,” she says.
Sarah believes “birth injury is a feminist issue,” explaining she was denied an elective Caesarian section despite reaching only 5ft 2in in height while her son’s father is more than 6ft.
Keighley says mothers-to-be should be better informed about risks, which include small women carrying big babies; maternal diabetes; mothers being of Asian ethnicity; and a first vaginal delivery.
There also needs to be “careful protection of the perineum, with mothers encouraged not to push as the baby’s head crowns to ensure the shoulders are delivered slowly – that’s when a baby can shoot out like a cork and cause damage,” he says, adding that if women need to be cut it should be at a 60-degree angle, away from the perineum.
Finally, there should be routine examination after assisted deliveries to detect injury to the sphincter muscle.
“Frankly, someone needs to stick their fingers up your bottom if you’ve had a forceps delivery,” Karen says. “It sounds disgusting – but anal incontinence is far worse.”
MASIC is calling on the NHS to implement a seven-point plan to reduce birth injuries, including training for medical professionals and awareness for pregnant women as well as specialist clinics and psychological support. A trial has seen the risk of severe injury decrease by 20 per cent.
“I had to have counselling to help me come to terms with what happened to me,” Karen says. “I was bitter for a long time.”
Remarkably, however, her experience didn’t put her off as two years later a son, now eight, joined the family. “Of course he was born by elective Caesarean, although I was petrified in case I went into premature labour,” Karen explains. “But I’m pigheaded – I didn’t want one doctor’s negligence to deprive us of our family.
“I also wanted to experience birth without the trauma. Consequently I can watch my children playing together now and say it has been worth everything I went through.”
But, as Sarah says, is that a price women themselves should still accept having to pay?
* The name has been changed