This week in Cosmo Australian blogger Zoe George graphically described how her vagina was ‘broken’ in labor. This Mom of 2 experienced a difficult forceps birth during her first baby’s birth. The words ‘broken’ and ‘vagina’ should never be in the same sentence but it’s a case of what you don’t know can hurt you and your vagina.
Pelvic floor injury and perineal injury is not a given in childbirth. There are things you can do to stack the odds in your favor of emerging from birth healthy and well and in most cases without a broken vagina.
Perineal trauma in modern childbirth has become so common place that women almost expect that they will need some ‘help’ in this last very important part of birth. Hollywood has us convinced that all that purple faced pushing is normal. The 2nd stage of labor becomes a frantic race to get the baby out as quickly as possible – suggesting to women that their own body is a danger to her baby. Your body has grown your baby from 2 cells to a perfect baby…knowing exactly where each fingernail should be placed….where your baby’s tiny ears should be placed….down the the perfect number of hair follicles on your baby’s head…with no conscious input from you…..no 'fetus growing’ classes…just the intelligence and wisdom of your body. Your body knows how to finish the process.
Most women who have experienced ongoing complications from a broken vagina have had traumatic births - in many cases it involves an assisted delivery with forceps or vacuum. As perineal injury becomes 'normalised’ we are losing sight of how physically and psychologically debilitating a damaged pelvic floor can be in day to day life and in a woman’s relationships with her partner.
In many maternity units the mom simply receives a referral to a physiotherapist to help her with the physical recovery but the emotional recovery and mental health issues (including depression) are not seen as being equally important. Day to day living can be a nightmare for these moms especially if they are experiencing fecal as well as urinary incontinence. These professional, healthy, young women have no control over their bowels and end up prisoners of their own homes and nobody is talking about it.
Sadly some women feel it was their fault because they couldn’t 'push’ properly or were too uptight and couldn’t 'let go’. So let me start off by stating that your body works. Your body knew exactly what to do. You weren’t too 'uptight’ or had issues with letting go. Your body did not fail you - but there’s a good chance that routine maternity practices most certainly did.
Even the most skilled yoga moms and the most laid back relaxed hypnomums are faced with the most harmful intervention in current obstetrics - not the forceps - but the clock. What many moms don’t realise is that they are on a time limit from the moment they are 'diagnosed’ to be in labor until the placenta is delivered - the clock is ticking. There is no evidence to support these arbitrary time limits especially for the 2nd (pushing) stage.
Here’s a typical scenario that plays out in our hospitals every day. Mom is managing well - baby is healthy and coping well with labour.
Mom has 2 hourly VE (vaginal exams) to ensure she is dilating with the hospitals guideline of 1cm per hour (there is no evidence to support 2 hour VEs)
Around 7cm (sometimes even at 10cm) Mums labor slows down as her body rests and as her baby rotates into the optimal position… Mom is deemed to have inefficient uterine action and is prescribed the Pitocin drip and her are waters broken. Mom is now on continuous monitoring due to the administration of Pitocin. Mom is finding it more difficult to cope with the chemically driven contractions that give her and her baby little or no rest between. Her baby finds it harder to recover from the intense, longer chemically driven contractions and is now showing late decels on the monitor. Mom is now 10cm and baby is showing signs of distress due to the Pitocin.
Additional staff enter the room and Mom is instructed to lie on her back and pull her knees up to her chest as 2 nurses shout at her to hold her breath and push into her bum (whether she has any urge to push or not). Sometimes staff will tell a mom to 'get angry with her baby’. Prolonged breath holding further restricts oxygen to her baby which again shows baby in distress and a decision is made for an assisted delivery. An episiotomy is performed and vacuum applied - vacuum fails and forceps applied. Baby is born limp and has low APGARS due to hypoxia (lack of oxygen). Mom is in a state of shock but thankful that her baby was 'saved’ Mum’s notes read - 'FTP’ - failure to progress and reluctantly accepts that this was her fault.
Nobody told Mom that holding her breath for long periods of time might not be good for her baby. Nobody told her that 'purple pushing’ could damage not only her baby, but her bladder, her pelvic floor and perineum. In fact the birth classes encouraged it and other women told her to 'listen to your nurse - she’ll show you how to push’. Nobody told her that if all is well that there is no hurry (even up to 3 hours is reasonable for a 1st time mom) when her body is doing most of the work.
Current evidence and international best practice would suggest that this was a case of 'failure to wait’ rather than failure to progress. In my experience there are several factors that increase the risk of perineal/pelvic floor damage
1 - Arbitrary time limits (time limits mean more assisted deliveries)
2 - Coached pushing
3 - Overuse of episiotomies
4 - Induction of labor
There are a number of studies comparing coached vs spontaneous pushing In 2003 the WHO recommended removing coached pushing from practice. Research from 1957 describes the damage to the muscles of the vagina and support ligaments after coached pushing so the new research is reaffirming what we already knew to be the case - that 'purple pushing’ is harmful for women and their babies and the more Moms can educate themselves about Irish maternity practices the better. I often hear Mums say not to focus on the birth as it’s 'just one day’…..but that’s not the case for those women who are living with incontinence for the rest of their lives. Information is power. My recommendations are the same to all women whether they have have had previous trauma to the pelvic floor or are first time Moms. It’s so important that women understand how the 2nd stage actually works.
The pushing stage is a reflex..when your baby’s head triggers Fergusons reflex your body automatically starts to nudge your baby down. The top of the uterus gets thicker and thicker and moves down around your baby - like a tube of toothpaste. When you think of how our body works when we feel sick and vomit. Your body throws up….so in labor it’s like your body is throwing 'down’. You’d never say ‘oh I had a dodgy curry last night and was pushing up vomit all night’….you’d say you were throwing up….it’s the same with the 2nd stage….your body does all the work for you but it feels sooo good to go with it.
It’s an irresistible urge that you can’t ignore. Think of how the bowel works - pushing when you don’t have the urge to push is like me instructing you now to go and have a bowel movement immediately when you don’t feel the need to go! Think of a time when you really really needed to go….did you need someone to coach you? Did you need to do anything else other than sit down and relax? Whether you sit on the toilet and push for gold or bring a book (men are great at this) the poop still comes out!!! When you think of it how did humans get out of the uterus for the thousands of years before Midwives and Doctors came on the scene? Who is coaching the cows and sheep in the fields or the women who have accidental homebirths or give birth in the car? I guarantee you those women pushing in the car are sucking their baby in to try to keep the baby there until they get to the hospital.
Mother led pushing is protective for your baby. When you hold your breath for sustained periods of time the oxygen to your baby is turned off (as well as oxygen to the uterus, pelvic floor and perineum.
What can you do to avoid a ‘broken’ vagina?
Avoid induction unless medically necessary.
Practice perineal massage in the 3rd trimester
Write your birth preferences down and discuss antenatally e.g. “I prefer not to have coached pushing but will push with my own urges”
Have your birth partner advocate for you in labor if a staff member starts instructing you to hold you breath.
Ask for more time if you and baby are well.
Choose an upright birth position even with an epidural
Focus on slow comfortable breathing - let your body do the work.
If you have an epidural request additional time for 'passive descent’ especially if you and baby are well.
Labor in water if possible.
Consider a homebirth or giving birth with a Community Midwives scheme (in 2008 a Swedish study showed a lower frequency of perineal injury associated with homebirths between 1992 & 2004). The risk of perineal/pelvic floor damage was 5 times higher in hospital. Or if possible choose a maternity unit or careprovider with a low rate of episiotomies and assisted deliveries to stack the odds in your favor.
Midwife Penny Armstrong describes her experience of episiotomy.
“One becomes accustomed to routines - including cutting of the flesh - and can get in the habit of not questioning their necessity. But if you are not accustomed to it, it is shocking to see vibrant muscle cut. I think of muscles as being strung out on our bones like strings on a cello - vibrating with potential, as if for an extended concert. I dream about a baseball player with his shirt off and the graceful cresting of power that curves up from the small of his back, across his shoulders and down his arms. to interrupt that progression of movement is an esthetic crime, and I feel sure we wouldn’t do it if it were avoidable. If a professional athlete was on a table in the operating room and if there was no other remedy but surgery, the prospect of cutting his muscles would still be sobering…seeing him prepped and draped, we would know that everything possible had been done….physical therapy, massages, slings…Only then would they resort to the knife. Maybe we don’t think of these women’s muscles with the same regard because of where they are located. We don’t see them crossing and gliding as they make our hips swing; we don’t watch them spreading into broad ribbony bands when we squat down. Because we can’t see them, maybe we think of them as a static crude vessel fit only for containing entrails, bowels and other oozy organs. Maybe that’s what makes them easier to cut… But I have seen the muscles in women. In the delivery room, when the cut was made across three or four major muscle groups, and I’ve seen them retreat and lie there, shrunk back into themselves, and I felt the same way I would if the athlete’s muscles had been cut. The same way I feel when a cellist’s string snaps during a concert. The music of the body, the resonance and the potential for rapture are interrupted”