Tackling the hidden trauma of childbirth injuries
23/05/11 | Complex wounds, Service development and delivery
Vaginal deliveries can cause distressing injuries, writes Jacqui Fletcher. But is enough being done globally to tackle this hidden problem?
Those of you who have been through a vaginal delivery will know that it isn't always the most comfortable experience - your perineum is stretched to the maximum as well as being traumatised by the pressure of the baby's head bearing down, sometimes for a considerable period of time. Even after the birth, your problems are not over. Post delivery you will learn to sit down with extreme care and become used to having to psych yourself up for a visit to the toilet. However, for the majority of women everything starts to get better after a few days - the pain subsides and they are able to get used to normal life again.
Unless of course they are unfortunate enough to sustain a tear or undergo an episiotomy. Then the pain and discomfort can continue for much longer.
As obstetric and midwifery practices develop, there is an increasing focus on reducing unwarranted interventions such as caesarian sections, which can mean that women experience a longer labour, sometimes resulting in episiotomy with forceps delivery.
Data on the frequency of episiotomies and more importantly episiotomy breakdowns are very difficult to find as there is often no central method of recording this information.
However, the impact of these wounds is immense. In the first place they are unexpected - most woman do not anticipate (however much information they have been given) that they will sustain an injury. Even if they are prepared they are generally told that any wound will be sutured and progress to healing. Most will have had absolutely no experience of what this type of wound looks like or feels like, after all it is unlikely to be a common topic for conversation at antenatal or postnatal clinic over a cup of tea. Furthermore, many women are not particularly familiar with the intricacies of that part of their anatomy in the first place.
As well as the physical ramifications, it can be hugely embarrassing to have to show an episiotomy wound to a midwife or a doctor, so many women struggle on with the pain and discomfort believing it to be normal. It can be some time before women become desperate and seek help.
For all of the above reasons these wounds present late and are often very complex to manage. As Puri and Leppert state later in the journal, changes to the anatomy and the strong elasticity of the rectal muscle frequently mean that any wound may disappear from immediate view, and it is only with thorough exploration the extent of the tissue damage becomes visible [Fig 1].
These wounds are in an area that is impossible to dress and extremely difficult to keep clean. The passage of urine and faeces across the area not only increases the bacterial levels, but may also cause considerable pain every time the patient goes to the toilet. Patients are often exhausted and struggling to breast feed - this is before they are started on antibiotics or pain killers, which may mean that they have to give up breast feeding altogether and feel they have failed. These wounds are not always large [Fig 2], but they are without fail painful.
It is concerning that we are unable to access enough data about women with these wounds. A brief review of practice in my local area showed that there is no consistency in approach with many 'old fashioned' practices still being used, for example, one local clinician reported cleaning wounds with witch hazel and drying the area with a hairdryer...
We would welcome any information about others' experience of managing these wounds and their frequency globally, as their management not only appears to be a hidden problem, but also one which is incredibly challenging.
Jacqui Fletcher is a Fellow, National Institute for Health and Clinical Excellence (NICE) in the UK and a Senior Professional Tutor