Maike was 40 years old when she gave birth to her daughter. The vaginal birth ends in disaster: Your pelvic floor tears off. What exactly happens and why nobody talks about it, explains Prof. Hans-Peter Dietz.
This text first appeared at this point at brigitte.de.
At 40, Maike is a late-giving birth. Pregnancy was anything but easy, plus the fear of childbirth and the panic of an epidural. Looking back, a vaginal delivery was the absolutely stupidest idea for Maike, she says today. But nobody warned them. Her daughter was very tall, already weighing 4500 grams at birth The practices of the midwife in the delivery room: old-fashioned and outdated. She is supposed to power press against the storm of contractions. With serious consequences: Maike suffers nerve damage and a torn pelvic floor. Even a year after the birth, she can barely lift her daughter. Shopping in the supermarket? No chance! Long journeys and even washing dishes are torture. Sex hurts too much, a second child? Not possible. Therefore, most of the time she lies on the couch or in bed.
She doesn’t know what her future will look like
Nothing unusual for Hans-Peter Dietz, Professor of Gynecology and Obstetrics at the University of Sydney. The pelvic floor specialist is the leader of a research group and THE reference for pelvic floor ultrasound worldwide. The kind of damage that Maike suffered can be prevented very easily – with a caesarean section, he says. A statement that is highly political, that many midwives demonize, but which could save thousands of women unnecessary suffering.
Despite two births, I’ve never heard of pelvic floor tears. How can that be?
Damage to the pelvic floor isn’t as obvious as a tear in the perineum or a tear in the vagina. So far, they have simply been overlooked because they are not immediately visible. The pelvic floor was hardly an issue in research until the turn of the millennium. Accordingly, it does not appear in the textbooks either.
Many women hear about their pelvic floor for the first time during pregnancy. What is it exactly?
The pelvic floor is a funnel-shaped muscle plate that is attached to the pelvic bone. Three channels run through this triangular opening: urine, reproduction and stool. This is what makes the pelvic floor so particularly complex. Incidentally, it looks completely different in primates, which shows that evolution in this area has progressed very quickly. And because baby monkeys are quite small compared to the birth canal, primates also have babies quickly behind a bush on the side. Unfortunately this is not the case for us humans.
Our babies are very large compared to the birth canal. Typically the opening in the pelvic floor is around 15 square centimeters, but it takes 68 square centimeters for a baby to fit through. No other skeletal muscle in the body would take it. It is therefore all the more astonishing that the pelvic floor muscle in a 32-year-old woman, i.e. a not very young first mother, looks 50 percent like it did before the birth.
According to their study, only 40 percent of women experience a normal birth without birth injuries. Why is that?
Women are on average 31 years old when they have their first child – significantly older than before. This is of course mainly due to the changed circumstances. Today women can decide for themselves when they would like to have a child, have access to modern contraceptives or decide to start a career. In principle, this is a good thing, but modern life has many disadvantages at this point, because the body is set up for something different than giving birth to a child at 38.
Age mainly affects the pelvic floor, which becomes stiffer every year. The consequences: the expulsion phase of the birth takes longer and the likelihood of complications increases. The risk of levator cracks, i.e. pelvic floor cracks, increases by six to eleven percent per year of life. A woman over 35 should be offered a caesarean section considering the likelihood of complications is simply too high.
“The forceps should be abolished”
What are the risk factors for permanent pelvic floor damage?
The most important factor that cannot be modified is the woman’s age. In addition to the size of the child, the weight of the mother, the position of the baby at birth and similar incidents in the family, the use of forceps is the most common cause of severe damage to the pelvic floor. Unfortunately, she has still not been banned from the delivery rooms because hospitals are under tremendous pressure to reduce Caesarean section rates. The forceps pulls out babies that would otherwise only come out by caesarean section. The caesarean section is notoriously terrible, ergo more and more forceps deliveries are made. In England, for example, forceps deliveries doubled between 2005 and 2015, which means 100,000 – 250,000 additional pelvic floor trauma, you have to imagine that this is catastrophic damage. The forceps for labor should be abolished.
How many women are affected in Germany?
Although forceps deliveries are not that popular in Germany, around eight percent of first-time women suffer from levator alvusion, i.e. a ruptured pelvic floor. With 800,000 births that is around 60,000 – in one year! Millions of women worldwide suffer from it.
How can you tell if something is wrong with the pelvic floor?
Serious perineal tears are usually discovered and treated immediately after birth, even if there is often a lack of diagnosis and follow-up care. The main symptom of severe perineal tears is faecal incontinence. A woman usually does not notice a levator tear immediately, but only after ten to 15 years because something else is more important than her own health. Only in the menopause do women take more care of their own health and go to the doctor. Symptoms of something wrong with the pelvic floor include: difficulty urinating and a pelvic wall hematoma right after birth. Later they often have no feeling or even pain during sex because everything is worn out. The partner usually feels this too.
What are the consequences of a pelvic floor tear? What can you do if you are affected?
A bilateral pelvic floor tear almost always leads to the lowering of the uterus and the bladder. This becomes clear in the menopause. The more severe the damage, the more difficult the operation. In Germany we are talking about 40,000 to 50,000 operations per year. A third of these cases are believed to be due to levator cracks.
There are now various experimental surgical procedures. In the future, we will hopefully be able to cure every prolapsed uterus or bladder, but that will probably take decades – as with the artificial hip joint back then.
Why aren’t women better educated about the risks?
For a long time we didn’t know that much about the pelvic floor. Nothing happened in research between 1955 and 2003. Our first study on this was published in 2005. And even now it will take years for knowledge to penetrate and for new methods to be established. In addition: The research into the pelvic floor tear is enormously political, because the alternative is the caesarean section. Even a midwife said to me: Research like yours should not be done. No matter how many women have problems afterwards.
What has to change in the future?
Expectant mothers need to be properly educated rather than romanticized by the ideology of natural birth. With every other operation and examination you do it meticulously, but not at birth. This is especially true for midwives who need to understand what exactly happens to the pelvic floor. Midwives and obstetricians sometimes unconsciously cause unnecessary serious damage, for example through incorrectly placed perineal incisions. At the same time, the diagnostic methods must be standardized and move into the delivery room in order to care for the women as well as possible.