In this blog Hannah Blackwell considers the impact perineal tears can have on mothers following childbirth and looks at the plans announced recently to try to reduce the incidents of these tears occurring.
The problem of women suffering perineal tears during childbirth has for many years been exacerbated by poor diagnosis, improper care and sometimes a reluctance of women to report their symptoms due to feeling embarrassed or believing they are just a complication of childbirth.
The British Journal of Gynaecology (BJOG) have reported that 85% of women have some form of tear during their first vaginal birth as the baby stretches the vagina. Most tears occur in the perineum, the area between the vaginal opening and the anus (back passage).
Classification of perineal tears
Perineal tears are classified as either first, second, third or fourth degree tears:
The number of women suffering severe 3rd and 4th degree tears has been reported by BJOG as having tripled from 2% to 6% between 2000 and 2012. The rise has been put down to tears being better diagnosed, but also women giving birth later in life and women having heaver babies.
Diagnosing a perineal tear
The Royal College of Obstetricians and Gynaecologists (RCOG) have produced guidelines to assist in diagnosing perineal tears.
The RCOG note that all women having a vaginal delivery are at risk of sustaining a tear and should therefore be examined systematically, including a digital and rectal examination to access the severity of damage, particularly prior to any suturing.
If a third or fourth degree tear is diagnosed then a repair should be carried out in an operating theatre under regional or general anaesthetic, with good lighting and the repair should be carried out by an appropriately trained clinician. 60-80% of women who have undergone such a repair are asymptomatic 12 months following the repair.
The importance of early diagnosis and repair of third and fourth degree perineal tears
In recent years, there has been much research undertaken highlighting the need for early diagnosis of third or fourth degree tears so that an early repair can take place which has the best chances of success. However, sadly some women who suffer these injuries do not have their tears diagnosed prior to leaving the hospital. Often for these women the injuries come to light when they experience unpleasant symptoms such as an inability to control their bowel or when faecal matter passes through the vagina.
I have represented a number of mothers who have suffered this type of injury during childbirth and the long term consequences for them are devastating. In some cases, mothers have had to have a colostomy bag to help manage their symptoms. Aside from the physical injuries, mothers can suffer psychologically, experience depression, loss of self confidence and self esteem and often their day to day lives are affected as they find it difficult to go out and about as they did previously, needing to be close by to a toilet.
New research to be undertaken
It was announced this week that there is to be a joint project between the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives to look at new techniques to try and reduce the risk of serious tears occurring. This is the first time doctors and midwives have teamed up to work together in this area and they will be looking at ways to prevent the weakest point of the perineum from being damaged in delivery. Over the next two years, more than a dozen hospitals are set to adopt the new techniques to be trialled.
I await the outcome of the study with interest and would also hope to see adequate training in place to ensure those caring for mothers during childbirth are appropriately trained to recognise such tears to enable mothers to have the best possible chance of a successful repair and also to provide appropriate follow up care and support to mothers with this injury. Sadly, I have seen all too often the devastating consequences the tears can have for mothers when they are not diagnosed appropriately or they experience an inadequate repair.