Childbirth injuries

We spoke to Swedish physiotherapist Tove Jendman – a specialist in obstetrics, gynaecology and urology – and asked her about tears, prolapse, levator ani injuries, and what people can do if they have a childbirth injury that doesn’t heal on its own.

Hi Tove! Is there anything people can do to reduce the risk of childbirth-related tears?

While it is possible to find a lot of advice and guidance on this topic, it is not actually certain that there is anything that can be done to reduce the risk. Anyone can experience tearing, no matter how you prepare for childbirth, and it doesn’t mean that you have done something wrong.

That said, there are factors in the actual birthing process that seem to have an impact, such as having good communication with your midwife, and ensuring that the expulsion stage proceeds calmly. There is also good evidence to suggest that the application of warm wet compresses against the perineum during the expulsion stage can reduce the risk of tearing. It is also said that the use of certain birthing positions – such as giving birth on all fours (hands and knees) or lying on your side – can help prevent tearing, but it is far from certain that you will actually end up giving birth in exactly the position you had imagined, as it is often the situation then and there that determines such things. A recently published study has also shown that having two midwives during the expulsion stage reduces the risk of tearing. There is also some evidence to suggest that perineal massage performed at least five weeks prior to delivery can reduce the risk of tearing, although this is fairly new information, and I am therefore looking forward to seeing more research on this topic.

What is the actual definition of a childbirth injury?

As far as I know, there is no generally accepted definition of a childbirth injury, but I have seen a Swedish report from 2021 in which it is stated: “Tears occur during most births and generally heal well. However, if the tears are not found and treated, or if they do not heal correctly, we define them as a residual childbirth injury. This means that the term childbirth injury shouldn’t be used until the tissue has had a chance to heal.” In other words, a tear in itself is not actually a childbirth injury, but it can become one if the tear causes lasting symptoms and problems.

What are the most common types of injuries that can occur after a vaginal delivery?

Tears are common and are usually graded on the basis of four different degrees of severity. A first-degree tear involves the skin and mucous membrane. A second-degree tear involves the mucous membrane and underlying muscle of the perineum. Third-degree and fourth-degree tears occur in connection with approximately 3.5 percent of vaginal births and involve varying degrees of injury to the sphincter and surrounding tissues.

The levator ani is a group of muscles located on either side of the pelvis. Levator ani injuries are also relatively common and are one of the sub-diagnoses of second-degree tears. Levator ani injuries occur in approximately 20–30% of vaginal births, as this muscle is stretched by 3 times its normal length during a vaginal delivery. A levator ani injury may occur on one or both sides of the pelvis, and the injury is classified as either microtrauma (stretching/minor tears) or macrotrauma (which means that the muscle is completely severed). People with minor tears often heal within a year, while others may suffer lasting injury, with or without discomfort. However, a levator ani injury is often more difficult to assess immediately after childbirth, as it is not visible to the naked eye.

What are the symptoms of a levator ani injury?

As mentioned, not everyone experiences discomfort, and it is therefore not always necessary to do something about it. But those with symptoms of this type of injury may experience a feeling of openness/wideness, difficulty doing pelvic floor exercises, pain, reduced sensation during sex or that their tampon/menstrual cup does not stay in place or ends up crooked. The pelvic floor, of which the levator ani is a part, provides support for the abdominal organs, and a lasting levator ani injury may therefore increase the risk of prolapse in the future.

What type of exercise is good for a person with a levator ani injury?

If you have a levator ani injury, it is important to do pelvic floor exercises in order to make the other muscles in the pelvic floor strong and supportive so that they can compensate for the injured muscle to some extent. However, it is not possible to compensate for a levator ani injury by constantly exercising the pelvic floor, as this will eventually cause pain. General strengthening exercises for the stomach, buttocks, arms and back are also helpful in distributing the abdominal strain that occurs when lifting etc. and can help relieve the pressure on the pelvic floor. If you would like more information, here is a link to an article about the body’s recovery after childbirth.

Do you have any advice for someone with perineal tearing after childbirth?

As a rule, third-degree and fourth-degree tears are monitored and followed up at the hospital where you gave birth. Some people also arrange a visit to a physiotherapist who specialises in this area. New mothers usually receive advice and guidance before they leave the maternity ward, as well as from their midwife during their follow-up visit, but a good general piece of advice for anyone who has given birth vaginally is to ask their midwife about the extent of their perineal tearing, so that they know and understand the situation. It can be helpful to use a mirror to view the tearing together with your midwife. Don’t be afraid to ask questions if there is something you don’t understand!

For those with second-degree tears involving the mucous membrane and underlying muscles, unfortunately the healthcare service does not generally have the same monitoring and follow-up routines as for more severe tears. However, it has come to light that many people in this group experience greater problems than was previously thought, and it can therefore be hoped that improved care will be made available to this group in the future. In the meantime, the best advice is to ask your midwife about the care and service that is available where you live.

Many people are worried about suffering prolapse after childbirth. What exactly is prolapse, and what causes it?

Prolapse occurs when the muscles and tissues that support your pelvic region weaken and stretch under the pressure of pregnancy and childbirth, to the point that your pelvic organs protrude into your vaginal canal (it could be the uterus, vaginal wall, rectum or bladder). However, everyone experiences a temporary bulging of the vaginal wall after a vaginal delivery – in other words, this is not a childbirth injury but rather a natural stage of the process that occurs when the baby stretches the vaginal wall on the way out.

A more constant bulging is more often associated with the time after menopause, but there are other factors that are also relevant to the risk of prolapse, such as the number of children you give birth to, physical work involving heavy lifting, prolonged constipation, type of connective tissue, a long-lasting cough, prolonged walking and standing, and a BMI in excess of 25. Lasting damage to the pelvic floor, such as a levator ani injury, may also increase the risk of prolapse in the future due to the pelvic floor becoming weaker.

What are the symptoms of prolapse?

After giving birth, many people often experience a sense of heaviness and a feeling of bulging. This is a symptom of stretching of the vaginal wall and other supporting tissue. The feeling is often less noticeable when you wake up and more noticeable at the end of the day when the body has been subject to gravity and various forms of stress. Other symptoms may include difficulty emptying your bladder completely, the urge to urinate, difficulty emptying your bowel, constipation or vaginal chafing. A constant feeling of bulging/heaviness should gradually subside after a few months. Sometimes, a tense pelvic floor can also cause symptoms such as chafing and a feeling of heaviness, in which case it is easy to interpret this as an indication of prolapse. However, unlike prolapse, which is affected by exertion and rest, the feeling caused by a tense pelvic floor is usually more constant and is made worse by stress/anxiety/fear, as the pelvic floor muscles react quickly to these emotions.

What can one do after childbirth to make symptoms of prolapse subside?

If you have recently given birth and are experiencing symptoms such as a feeling of heaviness and bulging, it is a good idea to take things a little easier, perhaps even lie down, until the symptoms subside. When walking, go for shorter walks to begin with so that you do not provoke a feeling of heaviness, as this will make it easier for your body to heal. Be sensitive to the symptoms at first – they usually get better as time goes on. To reduce the pressure on your abdomen, try exhaling when you are straining or exerting yourself, instead of holding your breath. You should also do your exercise in unstrained positions such as lying down or sitting, on all fours (hands and knees) or in some other position where you do not experience symptoms. Avoid carrying older children as much as possible, and ask for help when it comes to shopping and heavy lifting with a pram or stroller. When you go to the toilet, try to breathe deeply and avoid straining. It may also be helpful to use a laxative to aid your bowel movements, and to place a stool under your feet when sitting on the toilet.

What should someone do if they are told that they have recovered well physically after giving birth, yet it still feels like something is wrong? Where can people turn if they don’t feel that they are receiving the right help via the maternity care service?

I often hear new mothers say that, when the child was in their belly, all the focus was on them, but once the child is born, everything is focused solely on the child, and no one asks how they are feeling. This is symptomatic of a gap in the care service, and these women are often unable to find the right place to seek help for their physical problems.

First and foremost, it is important to be aware that your body is recovering throughout the first year after giving birth. When you attend your follow-up visit to the maternity clinic, it is still not that long since you gave birth, and your body is far from completely healed physically. Your physical recovery is a process that must be allowed to take the time it needs. If, for example, you have problems with urinary incontinence when exerting yourself during the first year after giving birth, you may need to change your exercise regime and your way of lifting, to reduce the strain on your body. But if the problems do not improve over time and you continue to have, for example, problems with pain in the coccyx or pelvis, urinary incontinence or a feeling of heaviness, you should seek help. In such circumstances, my advice is to contact a gynaecologist or a physiotherapist who specialises in women’s health. A physiotherapist is trained to examine the entire pain spectrum, including the pelvic floor muscles, abdominal muscles and the rest of the body, and can therefore help you to understand where your problems are originating.

If it turns out that the problems you are experiencing ultimately require surgery, a physiotherapist will recommend that you apply for the appropriate type of surgery. It could also be a good idea to check if there are any pelvic floor centres or clinics in your country that can receive patients on referral from other care providers. Unfortunately there may be long waiting times involved, and it must be said that the women’s healthcare service is under-resourced in many countries, but the benefit of the fact that women are now starting to talk about their problems is that it has become clearer that the need is far, far greater than was previously thought.

Many women feel that no one listens to them or understands their situation. Is there anything you would like to say to all the women who are currently suffering from their childbirth injuries? Or do you have any advice for their partners?

I usually say that you have an obligation, towards yourself, to take yourself seriously. You need to keep trying to find someone who can understand, examine and explain the problems you are experiencing. The human body is an amazing yet extremely complex system with many interrelated components, and it is not just your pelvic floor that undergoes change during pregnancy and childbirth. If you can gain a clear explanation and description of your symptoms, you will then have a good starting point when it comes to understanding the types of exercise and treatment you need. It can also become easier to deal with the tough periods if you know that things will improve once the extra strain on your pelvic floor disappears. It is also important to be aware that symptoms may come and go depending on a number of factors, such as your menstrual cycle, increased exercise or a cough you may have, and that old injuries can also sometimes cause symptoms and affect how your body reacts to a pregnancy, which is why it is a good idea to gain a holistic view of your body and find out what works for you and what doesn’t. Furthermore, we all need to keep in mind that the human body is made for movement, and that physical activity has a positive effect on both the body, mind and soul.

That said, the need for surgery is sometimes unavoidable, but it should be remembered that long-term pain also brings with it stress, sleep problems, anxiety, negative thoughts, impaired breathing and reduced physical activity, which in itself causes pain. These are the aspects that we can influence, but we often need help in order to be able to break free from these vicious circles of pain. Not all problems can be eliminated completely, but it is my firm belief that many symptoms can be improved with the right help.

Please note that all information above is based on Swedish recommendations.