What is birth injury?

Birth injuries are physical injuries experienced during childbirth. They can affect either the mother or the baby. In newborn babies, a birth injury (often called 'neonatal birth trauma') can include things, from bruising to a broken bone.

If you've given birth, injuries may range from tearing in the vaginal area, to damage the pelvic floor. Caesarean wounds can also be considered a physical birth injury.

Birth injuries in mothers typically fall into 2 main categories:

• injuries to the perineal area
• injuries to the pelvic floor

Injuries to the perineal area

• Perineal tears and episiotomy — around 3 in 4 women who give birth vaginally experience 'perineal trauma' (a tear or surgical cut to the area between the vagina and anus). These tears are at higher risk of complications and usually need more treatment and follow-up. A perineal tear may involve the:
  • skin of the perineum or labia (first degree)
  • muscles of the perineum (second degree, which is most similar to the depth of an episiotomy)
  • muscles controlling the anus and bowel movements (third degree)
  • lining of the anus (fourth degree)
• Nerve damage — occasionally, nerves in the perineal area can get damaged during childbirth, which can lead to a condition called pudendal neuralgia (long-term pelvic pain). You may experience pain around the vagina and perineum and sometimes down the legs. Bowel or bladder irritation, or a fullness sensation in the vagina or rectum can also occur.
• Obstetric fistula — this is a rare complication in Australia. This refers to a tear between the vagina and the bowel or bladder which causes an inability to control the passage of faeces (poo). It occurs when a third or fourth degree perineal tear high up the vagina goes through to the rectum (called a 'button hole tear') or if a perineal tear is deeper than estimated, is not repaired well, or an infection occurs.

Injuries to the pelvic floor

• Muscle damage — the 'pelvic floor' is a group of muscles inside the pelvis that helps hold the uterus, bladder and bowel in place. Many people who give birth vaginally have permanent changes to the pelvic floor due to over-stretching or tearing (avulsion).
• Pelvic organ prolapse — if the pelvic muscles are damaged or weakened, the organs inside the pelvis can drop down towards the vagina, causing bladder and bowel problems.

Symptoms of birth injury

Don't be afraid to ask questions as you may be the first to notice that something is not right.

Physical symptoms of birth injury may include:

• sweating, shaking, headaches, dizziness, gastro intestinal upsets or chest pains
• continued pain around after birth at the site of the episiotomy or tear (between vagina and anus)
• incontinence (inability to wee)
• difficulty emptying bowels (inability to poo)
• pain or difficulty having sex
• constant lower back pain

You may also find there is a physical change to your vagina presenting as:

• a bulge or lump at the vaginal opening
• a dragging feeling or as if something is 'falling out' — may be increased by standing, lifting, tiredness or during your period
• a looseness of the vaginal or pelvic floor muscle

Physical trauma during birth can include:

• tears to the perineum
• pelvic floor muscle damage
• pelvic organ prolapse (POP)
• pelvic fractures (this can include the pubic bone, coccyx or sacrum)
• caesarean wounds

Physical injuries due to birth injury require expert medical assessment and treatment.

Can physical birth injury impact me emotionally?

When you experience physical birth injury, you may also experience emotional or psychological distress related to what happened during the birth. This is known as psychological or emotional birth trauma. This can present as postnatal depression and/or anxiety, postpartum post-traumatic stress disorder or obsessive compulsive disorder.

Emotional birth trauma can also refer to how you, as the parent, feel after your baby is born. Sometimes the effects of birth trauma might first appear some time after you've given birth. Emotional birth trauma can continue long after the birth and many people don't seek support for months or even years. Some people think that they shouldn't be traumatised, but if your birth experience felt traumatic to you, then it was. You should seek help from your doctor as soon as possible.

There are many resources and professionals who can support your treatment and recovery from both physical birth injury and emotional birth trauma.

What are risk factors for birth injury?

If you suffer a birth injury, the cause was most likely something out of your control. Different birth injuries have different risk factors.

Some of the risk factors for birth injury include:

• having your first baby and your being older when you have your first baby
• the position of the baby, such as if it has its back to your back
• having a baby estimated to weigh over 4kg
• the length of labour or complications in labour
• shoulder dystocia
• assisted delivery using forceps or ventouse (vacuum)
• having a previous third or fourth degree perineal tear
• if you are of Southeast Asian background

Can birth injury be prevented?

Although it's often not possible to prevent birth injury, there are some things you can do during pregnancy and labour to reduce your risk.

• Strengthen your pelvic muscles with daily pelvic floor exercises and avoid constipation which causes straining and can weaken your pelvic floor.
• Perineal massage from 35 weeks pregnancy can reduce the risk of perineal tears and reduce the likelihood of needing an episiotomy.
• Ask your midwife to apply warm compresses to your perineum during the second stage of labour to help stretch the area to allow for the baby's head.
• Use breathing techniques during second stage labour, and stay active by moving around the room to encourage a slow controlled birth.
• Your doctor may recommend an episiotomy if you need an assisted birth to reduce the risk of a third or fourth degree perineal tear. This will only be done with your verbal informed consent.
• After a vaginal birth, your doctor or midwife should offer to perform an assessment for perineal tears, including an examination which involves a finger in your bottom (rectal or PR examination).
• Giving birth by caesarean could prevent some birth injuries, but it is a major surgery and carries risk. Carrying a pregnancy, regardless of how you give birth, puts strain on your pelvic floor and can cause pelvic floor injury.

You will make decisions about your birth as part of a shared decision-making process between you and your doctor or midwife. Unless it is an emergency, your health team will provide you with an explanation of any intervention, as well as the risks and benefits to you and your baby, before you can give your informed consent.

Consider creating a birth plan and getting tips on preparing for labour and birth. Your birth plan is a written summary of your preferences for when you are in labour and giving birth. You can also share your birth plan with your health team, and speak to your midwife or doctor about which birth positions you'd prefer to try.

How is birth injury treated?

Some birth injuries are minor and may heal on their own — for example, a minor perineal tear or graze. Other injuries need treatment at the time, such as a deeper tear that needs stitches. You may also need some pain relief.

If you had a significant tear or damage to the muscles of the pelvic floor, treatment may include physiotherapy and exercises to strengthen your pelvic floor muscles. Some women may need to use pessaries in their vagina or surgery to repair a prolapse. Sometimes, signs of pelvic floor damage or prolapse are not detected and treated until much later.

What can help my recovery?

The best way to help your recovery will depend on the type of injury you have.

If you have third or fourth degree perineal tears, your doctors will prescribe antibiotics to prevent your wound from getting infected. You will also be recommended to take pain relief and stool softeners, so you don't need to strain to open your bowels (do a poo). You will often see a physiotherapist to discuss looking after your pelvic floor and when to start exercises before you go home.

When can I have sex again after birth?

When you start to have sex again is a personal decision. It might be some time before you want to have sex.

If you've had a birth injury, speak to your doctor about their recommendations. They will consider your specific circumstances, so let them know if you experience any ongoing pain.

What follow-up appointments should I have?

Follow-up appointments with your doctor or midwife are important, particularly as some symptoms can take time to either settle down, or show up. For example, they may want to see you a few weeks after delivery and then a few months later. Make sure you understand your follow up plan before you leave the hospital.

If you have had a birth injury, you may be at more risk of it happening again with your next baby. Your doctor will talk to you about your options for your next birth.

Resources and support

• Speak to your doctor, midwife or obstetrician about your symptoms or any questions you have.
• Call Pregnancy, Birth and Baby on 1800 882 436 or video call to speak to a maternal child health nurse. Available from 7 am to midnight (AET), 7 days a week (including public holidays).
• Visit the Australasian Birth Trauma Association for information and support, including their peer2peer support programs.
• The Continence Foundation of Australia offers confidential information and support to people with bowel and bladder problems. Call the helpline on 1800 33 00 66 between 8am and 8pm (AEST), Monday to Friday excluding national public holidays.
• Visit PANDA (Perinatal Anxiety & Depression Australia) for information and support after a traumatic birth. You can call the PANDA national helpline on 1300 726 306 (Mon to Sat, 9am to 7.30pm AEST).