Psychological consequences of pelvic floor trauma following vaginal birth: a qualitative study from two Australian tertiary maternity units

Abstract

Vaginal birth may result in damage to the levator ani muscle (LAM) with subsequent pelvic floor dysfunction and there may be accompanying psychological problems. This study examines associations between these somatic injuries and psychological symptoms. A qualitative study using semi-structured interviews to examine the experiences of primiparous women (n = 40) with known LAM trauma was undertaken. Participants were identified from a population of 504 women retrospectively assessed by a perinatal imaging study at two obstetric units in Sydney, Australia. LAM avulsion was diagnosed by 3D/4D translabial ultrasound 3–6 months postpartum. The template consisted of open-ended questions. Main outcome measures were quality of information provided antenatally; intrapartum events; postpartum symptoms; and coping mechanisms. Thematic analysis of maternal experiences was employed to evaluate prevalence of themes. Ten statement categories were identified: (1) limited antenatal education (29/40); (2) no information provided on potential morbidities (36/40); (3) conflicting advice (35/40); (4) traumatized partners (21/40); (5) long-term sexual dysfunction/relationship issues (27/40); (6) no postnatal assessment of injuries (36/40); (7) multiple symptoms of pelvic floor dysfunction (35/40); (8) “putting up” with injuries (36/40); (9) symptoms of post-traumatic stress disorder (PTSD) (27/40); (10) dismissive staff responses (26/40). Women who sustain LAM damage after vaginal birth have reduced quality of life due to psychological and somatic morbidities. PTSD symptoms are common. Clinicians may be unaware of the severity of this damage. Women report they feel traumatized and abandoned because such morbidities were not discussed prior to birth or postpartum.

Appendix 1: Template of open-ended questions for interviewees

Introduction

• 1. Confirm that the participant has signed the consent form.

• 2. Explain the interview can be discontinued if the participant wishes.

• 3. Indicate that the participant can withdraw their responses later if required

• 4. Clarify there are no right or wrong answers.

• 5. Emphasize responses are strictly private and confidential.

• 6. Explain that some of the questions may be sensitive and personal.

• 7. Affirm that the researchers appreciate the assistance of participants.

Relevant participant information extracted from EpiNo database

Participant name:

BMI (Pre-& during pregnancy):

Height:

Date/ mode/ duration of interview:

Maternal age at delivery:

Email:

Mobile/Landline no:

Mode of Delivery (induction, epidural, Forceps, Ventouse, episiotomy, perineal and vaginal tears):

Ist Stage Labour duration:

2nd Stage Labour duration:

Baby weight/ head circumference/ position:

Estimated Date of Delivery:

Date of Delivery:

Gestation at delivery:

Postnatal Symptoms:

Domain 1: Pre/ Antenatal Care

• What did you know about childbirth at this stage?

• What did you understand about your body regarding childbirth at this stage?

• What or who was the source of your information?

Domain 2: Antenatal Care

• Where did you go for antenatal care and education - if anywhere?

• What can you remember about this experience?

• Can you tell me any information on childbirth and delivery you received during the antenatal period?

• What impact did this education have on you and your partner at that time?

• Now you have delivered would you change anything about your antenatal care and education?

• What were your expectations regarding childbirth, your health and living with baby at home afterwards?

Domain 3: Labour and Delivery

• How did you deliver your baby?

• Can you describe the course of events?

• Did you understand what was happening?

• How did you feel when baby was born?

• What was your partner’s reaction during labour and delivery?

Domain 4: Postnatal Period – in hospital

• Tell me about your experience in the postnatal ward?

• What physical changes to your body did you notice?

• When you passed urine or opened your bowels was there any difference from before birth?

• Tell me about any psychological changes at this stage after birth?

• Did these changes affect you while you were in hospital (if relevant)?

• Did you notice that your perineal area (around vagina and anus) felt any different?

• What was your experience of breast-feeding and time with your baby?

• Did you notice that your vagina felt different after the birth?

• Who did you tell about any alterations to your perineal area (if any)?

• What was your partner’s reaction to the postnatal stay?

Domain 5: Postnatal Period – adjustment at home

• Can you tell me about your physical health at this stage? For example: passing urine, opening bowels, vaginal sensation?

• How was your psychological health at this stage after the birth?

• Did you tell anyone about any changes to your physical and/ or psychological health?

• How was your relationship with your baby at this stage?

• How did you feel about your body image at this stage?

• Were your expectations prior to the birth similar to that which occurred?

• How were you feeling about sex?

• What was happening with your partner at this time?

• Did you want to debrief about your delivery at this point?

Domain 6: Long term - after the birth of the baby /before restorative surgery

• Can you tell me about your general physical health?

• Can you tell me about your emotional or psychological health?

• Is passing urine the same as before you were pregnant?

• Is your vaginal area the same as before pregnancy?

• Are you able to use tampons?

• Have you noticed anything different about your bowel habits?

• Can you tell me about your overall body image at this stage?

• Do you think childbirth has affected your activities of daily living?

• Are you able to discuss any changes to your urinary, bowel, vaginal or emotional health with anyone?

• Have you resumed sex with your partner? If so, does it feel any different to before your pregnancy?

• Do you know how your partner is feeling about sex with you at this stage?

• Do you still want to debrief or talk about your delivery?

• What are your memories of your labour ward and postnatal experiences now

Comments:

Confirmation of Accuracy of Interview Notes

This is an accurate account of my responses discussed with the researcher from Sydney Medical School, Nepean Campus, The University of Sydney. This research explores women’s experiences of physical vaginal birth trauma. I have signed and witnessed the relevant consent form and read the participant information sheet.

Name:

Date: