"Because this isn't a disease, I feel it gets regarded as an inconvenience and we are not given the same clinical priority."
Joanna Prance, Ambassador for The MASIC Foundation
Dr Louise Newson, a GP and menopause specialist, and Sanja Strkljevic, Partner in Leigh Day's medical negligence team, hosted an informative discussion on birth injury, subsequent incontinence, and how these issues can worsen during the perimenopause and menopause.
Louise and Sanja were joined by consultant urogynaecologist, Dr Ranee Thakar, Dr Radhika Vohra, a GP with special interest in women's health, and Joanna Prance, ambassador for MASIC Foundation , a charity supporting women who suffer from anal incontinence after childbirth. Joanna has lived experience of birth injury.
"Twenty one years ago I had a baby boy. The vaginal delivery left me with a perineal tear that was identified at the time as a second-degree tear. I was told this was very normal and I left hospital none the wiser but 18 months later, I began suffering with stress induced urinary incontinence. After multiple humiliating tests, endless appointments, and specialist physiotherapy, I had surgical treatment to support the urethra - only to find three months later I was now faecally incontinent too. I was soiling myself many times a day and had no idea that the problem was linked to childbirth. GPs and gynaecologists told me that it was Irritable Bowel Syndrome and had a psychological cause. I tried everything I possibly could to improve matters myself, undergoing a range of treatments. I ended up having 17 different operations over 20 years, including a colostomy bag last year. The impact of incontinence is devastating, not just for me but for my family too. I realise now that the perineal tear was most likely a misdiagnosed third-degree tear that involved my anal sphincter. Had my delivery and initial surgical repairs been managed effectively, the last 20 years of my life would have been very different."
As an ambassador for the MASIC Foundation (Mothers with Anal Sphincter Injuries in Childbirth), and with full endorsement from the other speakers during the webinar, Joanna clarified areas for focus as the Three Ps:
Promotion – improving awareness of risk of perineal injury in childbirth
All speakers agreed there needs to be an open and honest conversation about the risk of perineal tears and incontinence. Healthcare professionals, as well as women, need to realise that problems can surface years down the line, along any point in a woman's life, but especially around menopause. Far more education is also needed for girls and young women on the importance of the pelvic floor muscle, how childbirth and menopause can affect it, and how to look after your pelvic floor for the rest of your life.
"Pelvic floor health and continence need to be promoted as part of normal care for women both pre- and postnatally, like we promote contraception, so the woman sees it as part of a normal way of caring for herself moving forwards. If this happens, we will find women will embrace the topic much more - across every age and ethnic group - and they'll know where to seek help when problems arise."
Radhika elaborated on how this is especially crucial for women from Black, Asian and minority ethnic backgrounds:
"We have seen recently how women from BAME groups represent a higher prenatal and postnatal risk category for complications, and they certainly don't seek help for perineal injury, as much as other groups of women might. This is partly because of a cultural hesitation towards examination – which can be alleviated by good explanation – and also there is a lot of just living with embarrassing symptoms. There is a culture of accepting incontinence, which we need to address, as good continence treatment can make a huge difference to someone's quality of life."
Prevention – reducing occurrence of anal sphincter injuries
Third and fourth-degree tears of the perineum shouldn't be regarded as merely an unfortunate consequence of childbirth. While it may not be possible to eradicate their occurrence entirely, much can be done to reduce the frequency and severity of them and minimise the potential impact on women throughout the rest of their lives.
"I am very focussed on preventing anal sphincter injury during childbirth. There is a lot that obstetricians and midwives can do during labour, for example, episiotomy can help when indicated and when done correctly. 'Manual perineal protection' is a technique involving using a hand to squeeze either side of the perineum when the baby is being delivered - recent evidence shows this has a protective effect on the perineum - and if instrumental assistance is required, ventouse (suction) should be considered before using forceps. The Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists worked together on a project to produce the OASI care bundle (Obstetric Anal Sphincter Injury) and this includes these interventions, as well as performing a rectum examination on all women after delivery. The project was implemented in 16 maternity units in the UK. When used together, this group of interventions demonstrated a 20% reduction in anal sphincter injuries in childbirth. Support to implement the care bundle more widely has now been expanded to 30 units."
Protection – providing the best care possible
Ranee Thakar believes care after perineal injury is everybody's business:
"We must not compartmentalise care for these women into what is obstetric, what's for the midwife, for the nurse or GP – it is everyone's responsibility with the patient at the heart of it. We all have a duty to ask about the perineum and incontinence when we follow women up, to normalise talking about it, and provide that space freely – women are suffering with incontinence for far too long before getting the help they deserve."
One treatment that can be helpful to women, both after childbirth and around the perimenopause and menopause, is vaginal oestrogen. This acts by boosting low levels of oestrogen directly to the genital areas that need it, which in turn helps stop thinning of tissue, helps lubricate the vagina, eases discomfort, and helps fight off infection. Vaginal oestrogen can be taken safely, and indefinitely by most women, under the advice of a doctor.
Listeners were reminded that women can seek out a GP who has a special interest in women's health, and that they also have the right to ask for a second opinion from a hospital doctor, even if that means going outside the local NHS Trust.
Dr Newson and The MASIC Foundation have produced a booklet about menopause and perineal injury which contains more information about treatments and is free to download here.
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