Sydney Pelvic Floor Health

Antenatal Info

What you always wanted to ask in Antenatal Classes…

Childbirth is much safer for women and their babies today compared to what it was for their grandmothers. However, I don’t think having babies is any easier today than it was 30 years ago, and in some ways it has probably become more difficult, maybe even more dangerous. 

There are several reasons for that, and it is very unlikely that you will hear them explained in antenatal classes, which are often limited to discussing natural childbirth. 

On average, women in Australia are about 5 years older than their mothers were at the time of their first birth, and quite a bit heavier. Because of both, they have a much higher likelihood of medical complications, especially gestational diabetes. Their pregnancy lasts longer- which means that they are more likely to need an induction of labour, and their labours are more likely to be ‘dysfunctional’, ie., to not run smoothly. Both obesity and age may have something to do with that. 

Sometimes, antenatal educators blame obstetricians for interventions such as induction of labour, syntocinon use to make contractions stronger, Vacuum, Forceps and Caesareans, when most of those interventions are the result of lifestyle changes: women who have their first baby today are very different from those who came into Delivery Suite 30 years ago. In fact, it’s amazing that the likelihood of major disasters is still trending down, despite all those changes in the women we see.  

In a recent study of ours at Royal Prince Alfred and Nepean Hospitals in Sydney, we found that less than 1/3 of first- time mothers of singleton babies at term, after an uncomplicated pregnancy, ended up having a normal vaginal birth without major damage to the pelvic floor (that is, the pelvic floor muscle and / or the anal sphincter muscle).  

Less than one in three women got what everybody tells them is the norm- provided you do all the right things: don’t drink, don’t smoke, exercise, take your supplements, and generally listen to those who claim to know better. That’s dreadful. Most pregnant women are blissfully unaware of the very real dangers of childbirth. They are treated as if they were children, not competent adults.  

Doctors and midwives are morally and legally required to treat their patients as adults, unless there is a very good reason (such as a guardianship arrangement) not to do so. That means we need to tell you about the risks of childbirth.  

I remember one patient after a traumatic birth telling me: “Why didn’t anyone tell me things could be so bad?” I had no answer then, but now I’d say: Because those looking after you did not treat you as an adult. You need to know what you’re facing, otherwise you won’t be able to make your own decisions, and you’ll be shell- shocked if something unexpected happens. Forewarned is forearmed.  

So- there are a few things you need to know once you’re preparing for birth. It’s of course different for a premature birth, but by 36-37 weeks the following information will apply.  

1.) There is a small risk of your baby dying inside the womb for no apparent reason. We call that ‘unexplained stillbirth’. The risk is about 1:700 overall for babies around term. Every day the baby spends inside the womb carries a small risk. That’s why the safest time to be born is around 38 weeks. Once the lungs are mature (which they virtually always are at 38 weeks) there really is no benefit in staying inside the womb, but every day inside carries a small risk. That’s why we do inductions of labour (although mostly only well after the due date), and that’s why an elective (planned) Caesarean Section at 38 weeks is very likely the safest way to be born for a baby- although the pros and cons are more complicated for the mother (see the ‘Elective Caesarean’ entry on this web site -link).  

This is rarely explained in antenatal clinic or antenatal classes because it conflicts badly with natural childbirth ideology. The last thing anyone wants is for you to ask for an elective Caesarean, because that’s going to mess up the hospital statistics.  

2.) The likelihood of you needing an Emergency Caesarean in labour is quite high nowadays, at almost one in three. This can happen due to labour not progressing normally (‘failure to progress’), which is more common nowadays due to increasing age and obesity rates. The older you are and the bigger you are, the less likely it is for the uterus to contract efficiently and for you to be able to push the baby out. The other main reason for an emergency Caesarean is ‘fetal distress’, that is, the baby not getting enough oxygen through the placenta and becoming stressed- but of course thd risk of that goes up, the longer the labour lasts. So it’s often a combination of reasons that prompt the Obstetrician to suggest an emergency Caesarean.  

This means that Caesarean Section needs to be covered in antenatal education, and by people who can actually do such a procedure, ie., obstetricians. It’s a very safe procedure nowadays, but it’s still an operation. Usually it can be done under regional anaesthesia (spinal or epidural) which means you can be awake, and your husband/ partner can be there with you, with you getting the baby as soon as it’s out. Emergency Caesarean often isn’t properly discussed because staff don’t want to frighten you- as if you were a 6 year old, not an adult who has a right to know.  

3.) The likelihood of a ‘vaginal operative delivery’, that is, an obstetrician having to pull the baby out with a vacuum suction cup placed on the head, or with an obstetrician placing a Forceps inside the vagina, around the head, and pulling the baby out that way, is about 15%, that is, one in 7. In some hospitals, especially those who try hard to lower the Caesarean Section rate such as the Royal Hospital for Women in Sydney, it can be quite a bit higher. A vacuum is a bit less likely to succeed, but Forceps does a lot more damage, especially to the mother’s pelvic floor. For a discussion of the Vacuum/ Forceps issue, please see (link).  

4.) Even if you have a normal vaginal delivery (which is about 50/50), there is still a risk of a major tear of the pelvic floor muscle (over 10%), or of a major tear of the anal sphincter (also over 10%). For a discussion of what such tears mean, see (avulsion link) and (OASIS link), but I can tell you that you really don’t want either of the two to happen to you. From my experience it’s very uncommon for such damage to be discussed antenatally- not the least because we’ve only recently learned how common such tears really are, and what they mean for you.  

5.) There often is a bias against pain relief in antenatal education. Sometimes women are made to feel guilty if they ask for an epidural. That's just plain wrong, because there is no rational reason to avoid proper pain relief- unless you want to demonstrate how tough you are. It is claimed that epidurals cause Caesareans, and there is not a shred of evidence for that. In fact, from our data it seems as if Epidurals may protect the pelvic floor because they relax muscle. Epidurals can occasionally cause problems, but they are so much less important and so much rarer than all those other complications I've just mentioned.  

In gynaecological surgery we are required by law to explain complications that may happen in less than one in 100 cases. If we don’t do that and something goes wrong, the patient has a case against the surgeon or hospital, and the surgeon is in serious trouble. In maternity care, everything is different. It is as if Obstetrics and maternity care was not a part of modern medicine.  

Many women are blissfully unaware of the risks they run. Granted, many don’t want to know and prefer ignorance over knowledge. That’s OK- nobody should be forcibly exposed to information they don’t want. However, it’s the duty of doctors and midwives to offer up to date and accurate information, and many of us aren’t very good at that- due to habit, lack of information, lack of awareness of legal requirements, or sometimes due to a belief in magic: as long as we don’t talk about bad stuff it’s not going to happen.