Many women suffer debilitating pain and dysfunction long after delivering their babies. Elisha Clarke suffered severe pelvic floor dysfunction after giving birth to her son Will in 2019. She speaks of the trauma this caused and the impact it has had on her physical and mental health
An estimated 40pc of those who give birth vaginally suffer pelvic floor dysfunction that lasts for at least a decade. According to the MAMMI Study — a Trinity College study of the health problems of women during pregnancy and after childbirth — more than four in 10 women in Ireland experience stress urinary incontinence a year after giving birth, with 18pc suffering from painful intercourse.
“From an anatomical perspective, childbirth is poorly designed. If you were to start from the beginning, you wouldn’t do it this way,” says Dr Maeve Eogan, obstetrician and gynaecologist at the Rotunda Hospital Dublin. “Whether you’re having a C-section or a vaginal birth, there’s a degree of trauma involved, and for a portion of people there’s significant birth trauma, which may cause problems in the longer term.”
Dr Eogan is careful to emphasise that serious trauma is rare. While many women do tear, some heal without requiring stitches. “For minor tears, pain relief and changing pads might be all that’s needed, while for second-degree tears, suturing is a cornerstone of management,” she says.
Tears that affect the muscle of the perineum as well as the skin are referred to as second-degree tears, while third and fourth-degree tears — also known as obstetric anal sphincter injuries — extend into the anal sphincter muscle. Dr Eogan explains: “Third and fourth-degree tears require more significant repair and more frequently require transfer to an operating theatre. People who’ve had those tears will need antibiotics, medical and midwifery follow-up and physiotherapy. The most important thing is that it’s recognised at the time so that the woman can get the appropriate treatment. But that’s only about two women in 100.”
Elisha Clarke gave birth to her son, Will, in December 2019. She had been hoping for a home birth but ended up having to be induced, all of which went well and felt good for her until, when Elisha was 10cm dilated and struggling, the results of a foetal blood sample test made the atmosphere in the room change suddenly. “All I remember is chaos in the room,” Elisha says. “They lifted me onto the bed and my legs were put into stirrups, and there was one midwife in particular who was just shouting at me to push.”
Within 15 minutes of the chaos ensuing, Will was born through a forceps delivery with an episiotomy and additional tearing, after a failed attempt at using the suction cup. “It was a huge relief. All I kept saying was, ‘this is mad, I made a human’,” Elisha laughs. “I was high on oxytocin and just glad that it was over.”
Elisha was then informed that she needed surgery. Hours later, when she was brought back into a recovery room, it was explained to her that she had suffered what’s called a 3C tear, meaning that she had torn into the anal sphincter muscle. “I was in so much pain,” she recalls and explains that she only made it home for a week before she was back in hospital again with an infection at the site of the wound.
“It was the same doctor who delivered Will who was working that night, which I was really glad of, because she was familiar with the wound,” says Elisha. “The care after that was brilliant. They really looked after me.”
The first few months of the post-partum period were very tough and she suffered from both ongoing pain and incontinence. “I’d never heard of this kind of post-partum trauma, and I had no idea of the extent of the recovery,” she says. “Going to the toilet, holding onto the edge of the sink and the bath, I had to get my robe and put it over me and try to go into this place where I could almost meditate in order to go, because the pain was just out of this world.”
She attended the Poppy Clinic — a postnatal morbidity service at the National Maternity Hospital — every week after the birth, but the first national lockdown in the spring of 2020 meant that a referral to see a gynaecologist took months. In that time, her mental health suffered.
Elisha says: “I’d had some bad thoughts but thought I was getting on with things, but then around April, it came to a point where I had some really dark thoughts and I just knew it wasn’t right and I needed to get some help.” She adds that she’d been apprehensive about going on antidepressants as she thought they’d change her personality.
“But it was absolutely worth it. For the first few months I was in so much pain, I thought, ‘God, I don’t want to be a parent, I don’t want to do this, it’s too hard’. It took a long time to bond with Will, it was only really when I went on the meds. Since then, it’s been a lot more fun and I’m happy to get up in the morning.”
Elisha has since seen both a gynaecologist and a pelvic floor physiotherapist, as well as a colorectal consultant. “The involuntary sphincter is torn and you can’t repair that, though I’ve heard about someone who got a fake sphincter in,” she says, explaining that she’s hoping to avoid surgery. Instead, she has changed her diet and is trying to stay motivated to keep up the physiotherapy work. “I’m still leaking urine, but I’ve only had two faecal accidents this year. There’s some nervousness around that if I’m out and there are no toilets around, but overall, the recovery has been quite good.”
Pain-wise, she says time has been a great healer, but there are occasions when she resents having to do her physiotherapy exercises.
“When you’re a busy parent, the last thing you do is look after yourself. And doing something constantly every day for the rest of your life, you get fed up with it. But I just carry on; if I cough, sneeze or run, or when I tried to play basketball, that was a big no-no. Going to work, I’ll make sure I have spare underwear just in case, and back-up pads to be on the safe side. It’s part of my life now.”
It does cross Elisha’s mind every now and then that life might’ve been very different if she had a different birth. “Siblings are off the cards. We decided we couldn’t do it again,” she says, adding that she is a different person because of the experience. “Physically and psychologically it goes hand in hand. I don’t know if my body would look like this now if I’d had a normal birth, and then there was the knock-on with the post-natal depression.
“I’m doing OK, it is what it is now. It could be worse and people say you shouldn’t say that, but I also need perspective. I’m here, I’m able to carry on doing my job and we’re in a good place now, thankfully. It’s not the end of the world for me.”
Women’s health physiotherapist Elaine Barry sees a lot of women who want advice and reassurance after giving birth. Her first piece of advice for those in the early post-partum period is to take it easy and give the body time to heal. Elaine says: “Even if you don’t tear, there’ll be swelling and changes in the pelvic floor as a result of the birth. Generally, those who stay on top of pain management early on tend to do better because they’re able to move better, start light pelvic floor exercises, urinate and pass bowel movements more easily. They don’t have that reactivity that sets up a pain cycle.”
Echoing Dr Eogan’s advice to get any unusual pain checked out, Elaine adds that occasionally, pain can be the body’s way of telling you to slow down. “It could be a message to take more rest. If you can stand for 30 minutes and then you get symptoms, it’s a sign you need to lie down,” she says, stressing that it’s worth talking to your care provider about any sensation of the perineum opening more than before or pain at the scar site.
“Some women can develop granulation tissue at the top of the scar line. Some might feel it when they put their hand there, but it doesn’t bother them, while others experience sensitivity, which can contribute to pain during intercourse.”
At the very beginning, when attempting intercourse after childbirth, Elaine recommends using a lubricant to ease any fear or anticipation. Pain that is intense, however, is never normal, and no pain that is ongoing should be ignored. She adds: “It could be related to the scarline not being mobile enough, or the muscles could stay in a reactive phase for longer than we’d like. You should go to a pelvic floor physiotherapist to see what’s going on, but you could start with a gentle, external perineal massage in the shower, working your way around the scarline. Make small, circular motions with your index finger above and below it, not directly on it.
“Generally, scars respond well to gentle massage, and it’s good to prioritise learning to breathe into the belly to let go and relax. When the scar is fully healed, you can try some gentle hip stretches.”
So what about niggling pain that doesn’t go away, or problems that return years later? Occasionally, explains Elaine, hormonal changes due to the menopause, stress or dietary changes, can contribute to increased tone in the pelvic floor area, which can make a previously minor issue worse. Ageing and lifestyle changes can also trigger incontinence or pain during intercourse or high-intensity exercise.
“It’s about knowing what’s your normal,” she says. “Pain with intercourse shouldn’t be an issue for women, but we know it can be quite common in the perimenopausal and menopausal years due to both hormonal changes and pelvic floor tightness, which can be present for years but emphasised by the hormonal changes as we get older.
“We may be leading more sedentary lives as we get older, or perhaps we have put on weight. If you’re really stressed, see how you can reduce stress. These kinds of lifestyle factors have an impact on our pelvic floor health.”
Dr Eogan agrees. She says: “Even something simple like a thrush infection can spark symptoms that haven’t been an issue prior to that, but they’re often so easily remedied, it’s just important to get the right care and treatment.
“The reduction of oestrogen and female sex hormones during menopause can be associated with the reappearance of vaginal dryness and recurrence of pain with sex, but there’s a range of treatments, from lube to hormonal treatments, local or HRT.”
It’s difficult, she says, to give general advice on what to do to get to the bottom of lasting problems resulting from perineal trauma, because there are simply too many different paths. The key thing is to ask for help.
“It’s very healthy that people are talking about the pelvic floor impact of birth, because by talking about it they are accessing care and advice from peers and professionals,” she says.
Dr Eogan adds that you meet patients who think that there is a major problem, but it turns out that it is very easily remedied. “In the first instance, have an examination, either by a women’s health physiotherapist or your primary care GP.
“See if a referral to a gynaecologist is needed or if your problem can be managed with pelvic floor physiotherapy. Sometimes pain isn’t caused by weak muscles but by overly tight muscles, and physiotherapists have excellent techniques to resolve those issues.”
Finally, Dr Eogan highlights the importance of psychological healing and explains that many maternity hospitals now provide birth reflection workshops. “If you have questions about how the labour happened or about events surrounding your baby’s birth, contact the maternity hospital and you can get answers. Psychological healing helps physical healing as well.”