Perineal Injury and Maternity Practices in Ireland

national | consumer issues | news report Monday October 17, 2011 14:58 by Tracy Donegan

Pelvic Floor injury in Ireland today

Pelvic floor injury is not a given in childbirth. Mums can stack the odds in their favour of emerging from childbirth whole, healthy and intact.

Perineal trauma in Ireland 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 labour becomes a frantic race to get the baby out as quickly as possible – suggesting to women that their own body is a danger to their baby. But hang on a minute - 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 of the women I work with who have had serious ongoing complications of incontinence 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 hospitals the mother 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 women especially if they are experiencing faecal 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. Try to tell those women that the hospitals have no choice...that they have to have polices in place to speed up birth due to underfunding, understaffing, babybooms and the erroneous beliefs that the Mother's body is a risk to her baby.

Sadly some women feel it was partly 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 – infact your body ROCKS!.  Your body knew exactly what to do. You weren't too 'uptight' or had issues with letting go.  Your body did not fail you  - our maternity practices most certainly did. Even the most skilled yoga mums and the most laid back relaxed hypnomums are faced with the most harmful intervention in current obstetrics - not the forceps - but the clock.  What most Irish mothers don't realise is that they are on a time limit from the moment they are 'diagnosed' to be in labour until the placenta is delivered - the clock is ticking.  There is no evidence to support these arbitrary time limits but we have nearly 30,000 births between the 3 Dublin hospitals each year and only 30 delivery beds........do the math.  What do you think that will mean for a first time Mother? 

Here's a typical scenario that plays out in our hospitals every day. 

Mum is managing well  - baby is healthy and coping well with labour.
Mum 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 labour slows down as her body rests as her baby rotates into the optimal position
Mum is deemed to have inefficient uterine action and is prescribed the pitocin drip and her are waters broken (there is no evidence to support this)
Mum is now on continuous monitoring due to the administration of Pitocin.
Mum is finding it more difficult to cope with the chemically driven contractions that give her and her baby little or no rest between.
Baby finds it harder to recover from the intense, longer chemically driven contractions and is now showing late decels on the CTG.
Mum is now 10cm and baby is showing signs of distress due to the drip.
Additional staff enter the room and Mum is instructed to lie on her back and pull her knees up to her chest as 2 Midwives shout at her to hold her breath and push into her bum (whether she has any urge to push or not).  Sometimes a Midwife will tell a Mother 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).
Mum 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 this Mother that holding her breath for long periods of time was putting her baby at risk. Nobody told her that 'purple pushing' could damage not only her baby, but her bladder, her pelivc floor and perineum. In fact the antenatal classes encouraged it and other women told her to 'listen to your Midwife - she'll show you how to push'.

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 in Irish women.

1 - Arbitrary time limits (time limits mean more assisted deliveries)
2 - Coached pushing
3 - Overuse of episiotomies - NMH has an episiotomy rate of 43% for first time mothers.  Wexford's rate is only 8% and the MLU in Drogheda is 5%.   Evidence does not support the use of routine episiotomies.
4 - Overuse of epidurals and underuse of hydrotherapy (water immersion is associated with lower perineal damage)

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 Mums 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 Mums.   It's so important that women understand how the 2nd stage actually works.  That it's 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 labour 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.

 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 Ireland or bring a book (men are great at this) the poop still comes out!!!  When you think of it how did humans get born for the thousands of years before Midwives and Doctors came on the scene?  Who is coaching the cows and sheep in the fields? Women can give birth in a coma...

• 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 labour if a staff member starts instructing Mum to hold her breath.

• Ask for more time if you and baby are well.

• Choose an upright birth position especially if you don't have 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.

• Labour 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 with a low rate of episiotomies and assisted deliveries to stack the odds in your favour. Bump2babe.ie has all of the statistics.

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 tha curves up from teh 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"