Sydney Pelvic Floor Health

Tokophobia

Tocophobia: who is sane, and who is nuts?

Tocophobia means ‘fear of labout’, or ‘of childbirth’. It’s used to label women who are afraid of what may happen to them in childbirth, and in some instances such women have been referred to psychiatric services. We don’t agree with that. On the contrary, these women have a point. It’s not them who are ‘nuts’, it’s midwives and doctors who are ignorant of recent research findings and clinical realities. 

Damage suffered by mothers in childbirth is a common cause of pelvic floor problems. Women who have suffered birth trauma are often injured more seriously than generally believed. It often takes a long time for symptoms to develop. Urinary and faecal incontinence, prolapse and sexual problems are commonly seen as too embarrassing to discuss with clinicians, and frequently new mothers don’t remember much about obstetric procedures that happened without much explanation or explicit consent. Damage to the pelvic floor can also contribute to psychological trauma and even posttraumatic stress disorder (PTSD). 

Trauma to the perineum (the area between vagina and anus) and anal sphincter (the muscle around the back passage) has been the subject of clinical research for decades, but most of the more serious tears are missed in Delivery Suite. And even if they’re diagnosed, they’re often not well repaired (see MIND). Damage to the pelvic floor muscle itself is very rarely diagnosed, mainly because the vagina can stretch more than the muscle underneath. Often those muscle tears are invisible because the overlying vaginal skin is still intact. 

The main risk factor is Forceps. Vacuum is much less damaging, especially for the pelvic floor muscle. After Vacuum or normal vaginal delivery, 12-13% of all first- time mums suffer major tears, but after Forceps it’s 40-50%. That’s bad news because there is a strong trend towards Forceps and away from Vacuum in the UK (Forceps has doubled from 3.3 to 6.8% over the last ten years), and this is now also happening in NSW (see ‘What does this mean for me’). 

To date, there is very little research of mothers’ own perceptions of childbirth-related trauma. This is not surprising, given that most midwives and obstetricians are not aware how common such damage really is. In addition, such injuries are often not acknowledged as the cause of chronic pelvic floor problems. A study of first-time mums showed that only 15% reported problems on intercourse after childbirth and discussed it with a health professional, yet 64% suffered such problems 6 months after their birth. There are no reports on male perceptions of postnatal sexual health. 

Subjective experiences of Australian women 3-6 months after the birth of their first baby reported reduced pelvic floor function, especially by those with major pelvic floor muscle tears (‘avulsion’). Such trauma was related to subjective pelvic floor muscle function and vaginal tone, but not with more conventional measures of sexual function. 

Childbirth can also have a major impact on mental health. Birth is typically recognised as a benign ‘natural’ event, despite huge changes to the way the body works, and despite breaches of bodily integrity never observed in normal life. A British study of women after childbirth noted that 20 to 33% reported to be psychologically traumatized. Mode of delivery, forceps procedures and anxiety about complications after vaginal birth were mentioned most often. Postnatal anxiety disorders appeared more common than depression, with up to 16% of women suffering from panic, phobia, acute adjustment disorder or PTSD related to the events of birth. 

In another study, three groups of symptoms were recorded: re-experiencing the event; avoidance and numbing; increased startle response, irritability and anger. Postpartum PTSD was noted to have secondary effects on the infant, existing children and the family unit as well as being associated with other psychological problems such as depression, anxiety and substance abuse. 

Research on factors relating to pregnancy, childbirth expectations and delivery noted that PTSD symptoms were more likely in women who had delivered vaginally and received less pain relief during labour. An Australian review examining the effectiveness of psychological debriefing after traumatic childbirth showed that women during painful births sometimes come to believe that their bodies are torn or destroyed irreversibly.  

The WHO defines sexual health as: “the integration of the somatic, emotional, intellectual and social aspects of sexual being, in ways that are positively enriching and enhance personality, communication and love.” Mothers who are traumatized by childbirth demonstrate that for some women this state of well-being is not achievable after childbirth, at least not in the short term. While the causes of somatic and psychological trauma are by no means identical, risk factors clearly overlap, and it is likely that somatic trauma contributes to psychological trauma.  

The most severe consequence is posttraumatic stress disorder (PTSD). This is far more complicated than post-natal depression because it is a direct result of the bodily damage done in childbirth- and the mother may feel compelled to be grateful to the staff that actually caused this damage in the first place! 

Some women have nightmares and flashbacks and often feel unable to go near a hospital or look at pregnant women because it reminds them of their suffering. The outcomes of a wrong diagnosis by doctors are serious because women are commonly prescribed anti-depressants, which make them even less able to cope. They frequently experience problems in relationships with their baby and partner. Even male partners can suffer PTSD after being present at a traumatic birth, and due to fear for the lives of a partner and/or child.


What does this mean for women and their caregivers?

Before the birth

It is obvious that most health professionals do not inform pregnant women of the likelihood of pelvic floor damage, and they lack education in dealing with injuries much worse than anticipated. In all of medicine, doctors, nurses and other professionals are required by law to talk about risks and complications. Informed consent is compulsory for surgical procedures, and we have to mention complications that happen to one in hundreds of women.  

Antenatal care rarely touches upon the possibility of maternal birth trauma, whether psychological or somatic, even though major damage to the pelvic floor happens to at least one in five, and even though major psychological problems happen in at least one in 20. And if women have obtained information from elsewhere and are worried about what’s going to happen, they are labelled as ‘tocophobic’, that is, mentally abnormal in some way. This clearly has to change- doctors and midwives need to read up on the types of damage that happen in vaginal childbirth, they need to talk about these matters before childbirth, and they have to take women’s concerns seriously. 

If you feel worried about doctors or midwives making decisions that could mess up the rest of your life, make a birth plan, feel free to ask for (and, if necessary, insist on) an epidural. That will make sure that you stay capable of making your own decisions. And absolutely insist that Forceps be avoided. A recent case at the Royal Hospital for Women in Sydney suggests that you need to put this in writing and have it witnessed by a doctor or midwife. A clear written statement of your wishes, preferably witnessed by a staff member, needs to be complied with- unless the treating doctor wants to risk a court case. 


During the birth

Studies have shown that doctors and midwives have a very limited understanding of what happens to the mind and body in childbirth. This means that they’re quite likely to make decisions that do more damage than necessary. In 2015, nobody should have to have a Forceps delivery. There has not been a Forceps in Denmark for ten years, in Sweden it’s very rare, in Germany Forceps happens in only 1 in 200 women, and it’s the same in the US. Most of those countries have similar or better maternity outcomes than England or Australia. If entire countries can do without Forceps, why do we need it here? 

There are other risk factors that can be avoided: trying to have a second baby normally after the first was born by Caesarean is generally a bad idea. The second baby is usually bigger, the uterus is contracting more strongly in some, and mum’s tissues are older: the cards are stacked against a normal birth without problems. And then there is the risk of the womb rupturing, and an increased risk of the baby dying. In a recent study at St George’s Hospital in Sydney, the success rate of VBAC (that is, a normal birth after a first CS) was 75/ 226 (33%), and that came at the cost of two dead babies and one seriously sick mum.  

Another issue is pain relief. The better the pain relief, the lower the likelihood of post traumatic stress disorder, and the more you can stay in control and make you own decisions. Some people blame epidurals for all kinds of problems- most of it is pure propaganda. Epidurals certainly don’t increase the likelihood of a Caesarean. And Epidurals may even protect the pelvic floor because a relaxed muscle is less likely to tear. 

A third is the length of labour: the longer active labour lasts, the more stressful it is for the mother, and the higher is the likelihood of all kinds of complications such as bad tears and heavy, life- threatening bleeding. 

There is a great opportunity and need for research into the effect of changes in obstetric management, but such research is useless unless we can actually diagnose the damage to pelvic floor structures. That’s why just about all studies that have been done on perineal protection, episiotomy, birth position, water birth etc. are almost completely useless. The people doing those studies missed over 80% of the bodily damage that happens in Childbirth, and they almost always ignored the mind! 


After the birth

Doctors and midwives need to learn to understand what actually happens to mums in childbirth. Most really don’t have much of an idea. It’s not surprising therefore if the people women deal with are a bit clueless, and don’t understand that some women have major problems after a vaginal birth. Women need to insist that they need help, and suggest that professionals read up on recent literature. A good start are two recent review articles published in the local obstetric journal ANZJOG (“Psychological and somatic sequelae of traumatic vaginal delivery: A literature review”, Skinner and Dietz, ANZJOG 2015; DOI: 10.1111/ajo.12286, and “Pelvic floor trauma in childbirth”, Dietz HP; ANZJOG 2013; 53: 220–230). This journal is available to every obstetrician and many GPs in Australia, and most hospitals would have it in their library. 

The first step to proper care always is diagnosis. If there are major issues with postnatal depression or even postnatal stress disorder- if women feel they’re not coping and need help, then they need to see a doctor and insist on referral to a postnatal mental health service. If women feel that they have suffered bodily trauma then often physiotherapists are better informed regarding these issues than family doctors. And, if specialist medical help is needed then it may be a good idea to see a gynaecologist who specialises in pelvic floor problems. Proper diagnosis will need imaging, and such services are still limited to the capital cities, but many gynaecologists and urogynaecologists will know how to access such services.


Conclusion

There has been quite a bit of research into psychological and bodily trauma after childbirth over the last ten years, even if there still is lots to learn. Pelvic floor trauma is much more common than previously believed. Major anal sphincter and levator tears affect at least 30% of first-time mums delivered vaginally. Only a small proportion of anal sphincter trauma is optimally repaired, and major levator trauma is rarely diagnosed and never repaired.  

The psychological effects of traumatic childbirth on the health of women are poorly researched. The literature suggests that health professionals commonly lack awareness of these issues. Modern imaging has greatly simplified the diagnosis of damage to the pelvic floor and anal sphincter, but there is an urgent need to learn more about women’s perceptions of traumatic childbirth and resting mental problems. It is high time that the ‘hidden cost’ of traumatic childbirth was given the attention it deserves.