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Broken Vaginas – Understanding and healing Maternal Birth Injuries

In the process of childbirth, I experienced a third-degree tear extending from my vagina to my anus, leading to a combined pelvic organ prolapse. Facing challenging physical and psychological difficulties, I encountered shame, misjudgment, and ignorance. For months, doctors dismissed my pain as emotional until I was finally properly diagnosed and began my long journey to recovery. In my experience within the German health system, there’s a strong push for vaginal birth, labeled as ‘natural,’ with reassurances that complications are minimal. Yet, my vagina was broken. Wasn’t my injury foreseeable? And is there a happy ending to my story? The question is: Why do broken vaginas happen? Every…

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 Diagnosis and Treatment of Obstetric Anal Sphincter Injuries: New Evidence and Perspectives

Perineal injury during childbirth is a common event with important morbidity associated in particular with third-and-fourth degree perineal tears (also referred to as obstetric anal sphincter injuries—OASIS). Early diagnosis of these damages is mandatory to define a prompt therapeutic strategy and thus avoid the development of late-onset consequences, such as faecal incontinence.

Articles of Interest

Obstetric Anal Sphincter Injuries (OASIs): The Women’s Health Physiotherapy Treatment

The fear of perineal tears is real. However, the most effective way to address it is through open conversation and strategies to minimise the risk. Birth is a natural process, and many women have given birth even without medical intervention. Having this information shouldn’t change the desire for a natural birth; instead, it can empower you to actively participate in your delivery.

An Unspoken Risk of Vaginal Birth

Mainstream publications frequently report that only 3 to 5 percent of mothers are affected by third- and fourth-degree tears – the ones that affect the anal sphincter – but anecdotal evidence (in the form of friends and wine) suggested otherwise. And, indeed, a study in The New England Journal of Medicine has shown that the 3-to-5-percent figure reflects only tears detected clinically after birth (when things are messy and ill lit). When mothers were later given endoanal ultrasounds, it was revealed that 35 to 41 percent had suffered injury to the sphincter, which can cause fecal incontinence, painful fissures and discomfort for years.

Anal incontinence and unrecognized anal sphincter injuries after vaginal delivery...

Vaginal delivery is known to be one of the risk factors for anal incontinence among adults, and women with obstetric anal sphincter injury (OASIS) have higher risk of severe anal incontinence than women without such injury.

Anal sphincter injury

The internal anal sphincter is mainly responsible for anal closure and continence during rest, while the external anal sphincter plays the main role during increased intra-abdominal pressure e.g. during coughing Perineum stretching during vaginal delivery can cause anal sphincter injury by direct trauma to the muscles or injury to the pudendal nerve.

Anal sphincter injury: Under recognized and inadequately treated

As important as the fistula problem remains, it is vital to remember that obstetric injury of the anal sphincter, which will occur in about 10% of women who give birth vaginally, also has long-term sequelae. Damage to the sphincter is likely to have a significant adverse effect on a woman's emotional and physical health. It can lead to embarrassment, anxiety, depression, and reluctance to consider future pregnancies. Many women feel unable to discuss the symptoms they experience and avoid seeking medical opinion

Care of a third- or fourth-degree tear that occurred during childbirth (also known as obstetric anal sphincter injury OASI)

6–8 in 10 women with a third- or fourth-degree tear will have no long-lasting complications after it has been repaired and given time to heal.

Does the Finnish intervention prevent obstetric anal sphincter injuries? A systematic review of the literature

A series of seven observational studies from Nordic countries have found a reduction inf OASIS after the introduction of the Finnish intervention for all vaginal births when compared to periods or settings in which it was not routinely used. The procedure, here subsequently refered to as ‘the Finnish intervention’, is a package of care introduced in Norway. It consists of four elements: good communication between the accoucheur and the delivering woman; the ‘Finnish manoeuvre’; use of a delivery position that allows visual examination of the perineum during the last minutes of delivery; and mediolateral episiotomy on indication.

Management of obstetric anal sphincter injury: a systematic review & national practice survey

Obstetric anal sphincter injuries may be seen at the time of birth ('overt') or may be detected only after additional ultrasound investigation, after birth ('occult'). The incidence of 'overt' anal sphincter injury has previously been reported as being between 0.5–3% of vaginal deliveries. Until recently, anal incontinence not due to 'overt' anal sphincter injury was attributed to pelvic neuropathy. The advent of anal endosonography altered this view by identifying further 'occult' obstetric trauma to the anal sphincter.

Methods of repair for obstetric anal sphincter injury

The risk factors for obstetric anal sphincter injuries include a midline cut of the perineum (episiotomy) to facilitate the birth, forceps delivery and the baby’s back presenting posteriorly (occipito-posterior position). Most women give birth without any significant damage to their perineum or back passage. However, in about 1% to 4% of births, there is tearing and damage which extends to the back passage and the anal sphincter. This can cause considerable problems for some of these women in terms of pain, painful intercourse and faecal incontinence.

Not polite cocktail conversation (yet): obstetric anal sphincter injury

One injury that can occur during vaginal childbirth that all too frequently affects a woman profoundly for the rest of their lives is injury to the anal sphincter complex. Sometimes there can be tears of the vagina, pelvic muscles and connective tissue during vaginal delivery. Most of the time these tears heal quickly with the help of suturing by a birth attendant. However, in somewhere between 1% and 5% of deliveries, the tear of the perineal tissue extends into the anal sphincter and even lower rectum. These are among the most serious childbirth injuries for the mother; and although significant improvements have been made to reduce the incidence of these devastating injuries, (for instance by not performing routine episiotomy for births that do not involve the use of forceps or vacuum assistance), they will probably never be completely preventable.

Obstetric anal sphincter injury (OASI) in the presence of an intact perineum

At time of vaginal delivery, 65%–85% of women are expected to have some form of obstetric perineal injury. These obstetric injuries are classified from first degree to fourth degree. Third-degree and fourth-degree tears involve the anal sphincter complex and collectively are known as obstetric anal sphincter injuries (OASI) and occur in 4%–9% of mothers delivering vaginally. The incidence of OASI injuries increases with certain risk factors including: nulliparity, maternal age, induction of labour, fetal macrosomia, fetal malposition, occipito-posterior position, compound presentations, a short perineum, Asian ethnicity, prolonged second stage of labour, operative vaginal deliveries (ventouse and forceps) and shoulder dystocia.

Obstetric Pelvic Floor & Anal Sphincter Injuries

Perineal and vaginal injuries are common during childbirth, and up to 80% of primiparous women need suturing after a vaginal delivery. First and second degree perineal injuries rarely cause long-term health problems, but third and fourth degree injuries, which include anal sphincter muscle trauma, are associated with increased risk for anal incontinence (AI), pain, discomfort and sexual dysfunction.

Prevention of obstetric anal sphincter injuries with perineal support and lateral episiotomy: A historical cohort study

We observed a long-lasting reduction in OASIS rates after implementation of preventive procedures. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with an instrumental delivery. Special attention should be paid to deliveries with persistent OP position.

Underdiagnosis of internal anal sphincter trauma following vaginal delivery

Damage to the anal sphincter during childbirth remains the leading cause of fecal incontinence in women. Defects in the internal (IAS) or external anal sphincter, alongside symptoms and sphincter tone, will generally dictate the suggested mode of delivery in any successive pregnancy.

Resources

MASIC Foundation

We are advocates for women and aim to change the lives of those injured during childbirth. The MASIC Foundation is the only multi-disciplinary UK charity to support women who have suffered severe injuries during childbirth known as OASI (Obstetric Anal Sphincter Injuries).

Pelvic Floor Center

A sphincter injury refers to a tear or damage to the muscle that surrounds the anal canal. The anal sphincter muscle consists of two muscles; the internal sphincter and the external sphincter muscle. These muscles are used to control bowel movements. Damage to one or both of these muscles can result in the decreased ability to control bowel movements and can contribute to symptoms of accidental bowel leakage.