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Focus on birth injuries: “Unfortunately, these problems have been considered normal”

Most women will sustain some injury to the genital area when giving birth; however, for some of them the problems become permanent. Helena Lindgren is researching the role of the midwife and whether better methods could reduce the risk of vaginal tearing.

Helena Lindgren. Photo: Joel Nilsson

When the Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) conducted a review in 2016 concerning the state of knowledge regarding birth injuries to mothers, the results were discouraging. Within almost every area, whether it was tearing, incontinence or residual problems with pain, there was a lack of scientifically proven knowledge. At the same time, such injuries are common, according to Helena Lindgren, midwife and docent specialising in reproductive health at Karolinska Institutet.

“There has been rapid development in the field over the past ten years, whereas before, the knowledge of these problems and the possibilities for treatment were limited. Unfortunately, symptoms associated with childbirth have been considered normal, and many women have thought they just have to live with them,” she says.

Although the injuries can be serious, most of them will not cause any permanent problems.

“The most serious problems are caused by larger vaginal tears, and tears that involve the anal sphincter muscles,” she says.

Serious injuries

Around 4–5 per cent of those giving birth in Sweden today will suffer some form of serious tearing, i.e. damage to the anal sphincter. For most, the problems can be corrected with the help of surgery, but some will be left with permanent damage. Significantly more common are the second-degree tears that affect roughly half of all those who give birth vaginally (see fact box).

Helena Lindgren and her colleagues have studied various symptoms stemming from childbirth injuries, with one study looking at how approximately 460 participants graded their pain following their first childbirth. Out of those who had sustained second-degree tears, more than one in three estimated that they had severe or moderately severe pain in the genital area one year after the delivery. Urinary incontinence is also common. When 600 women answered a survey one year after childbirth, as many as four in ten reported that they were still experiencing problems of such a magnitude that it disrupted their everyday lives. A third study looked at the prevalence of haemorrhoids.

“Nearly one in four women were experiencing problems with haemorrhoids after one year, which corresponds to as many as 25,000  women every year. They said that they felt a bit unclean and had trouble resuming their sex life,” she says.

Previous research shows that the management of the final stage of the birth may affect the prevalence of childbirth injuries. In many high-income countries, women give birth lying on their backs or half-sitting, positions that do not reduce the risk of childbirth injuries. In Sweden, the tradition has been to encourage the child to be birthed in a single contraction, something that Helena Lindgren calls a “Swedish invention” that has not been adopted in other countries.

A more controlled second stage of labour

She has evaluated a method referred to as the Midwives’ Management During the Second Stage of Labour, or MIMA. An important part of this method is a slower and more controlled second stage of labour. In a study published in the journal Birth in 2017, the midwives at two maternity clinics in Stockholm were trained in this method, and it was compared with a traditional approach. All in all, the study included almost 600 first-time mothers, and with MIMA, the proportion of second-degree tears went down by a little over 11 per cent.

“If this method was applied nationally, this would correspond to 3,200 fewer first-time mothers suffering a second-degree tear every year. And the proportion of anal sphincter injuries went down by 25 per cent,” says Helena Lindgren.

The method involves giving birth on your knees, on all fours, lying on your side or sitting on a birth stool – all positions that allow for pelvic mobility. It is important to avoid lying on your back, as this position reduces the flexibility of the pelvis. It is also important that the person giving birth is not rushed to push the child out in one contraction, but instead the head is delivered first, and then the rest of the body is pushed out with the next contraction or in between contractions. This allows the baby to turn spontaneously, and the risk of tears is reduced.

“Midwives have been taught that there is a rush, but this is not the case in a normal birth, where the child receives oxygen through the umbilical cord. Part of the MIMA training is also having the midwife reflect on whether there is any danger to the health of the child or the mother, or if it is ‘simply’ a matter of the midwife feeling stressed,” says Helena Lindgren.

The method is taught at Karolinska Institutet, and at the time of writing, 600 midwives and obstetricians have completed the training. 

“Midwives are taught the method to take an active role in the birth, to suggest good positions and support the woman in giving birth in a way that is gentle on her and the child, and which makes it a positive experience,” she says.

Two midwives together

There are currently other studies underway, including one that investigates whether the prevalence of childbirth injuries is affected by having two midwives managing the final stage of the birth together. 

Childbirth injuries are an international problem, and in low-income countries they can result in extensive bleeding and lethal infections. Today, Helena Lindgren is leading a research project in Gondar, in northern Ethiopia, where only one woman in four gives birth in a hospital.

“When the women give birth at home, they tend to choose traditional birthing positions, like the ones used in MIMA, but in the hospitals they receive very authoritative treatment and have not been permitted to give birth in any position other than lying on their back, and usually with ten to fifteen people in the room looking at them,” says Helena Lindgren.

In the study, which will be initiated next autumn, they will see whether it is possible to introduce a method where women are allowed to give birth in a setting more similar to home, preferably with someone to accompany them and in a flexible position.

“In Malawi, we have seen that the increased freedom of choice can encourage women to give birth in hospital. We hope that this will help more women to give birth safely, but we will wait for the results of the study,” she says.

Many women suffer from tearing

Today, the most common childbirth injury in Sweden is tearing.

  • The injuries are graded on a scale from 1, which is comparable to an abrasion that heals quickly, to 3 and 4, where the tear also involves the anal sphincter.
  • Second-degree tears are divided into the categories a, b and c, with c being the most severe. They involve tears in the vaginal muscles, which cause a sense of heaviness, wideness, pain during sexual intercourse and a risk of urinary incontinence.

Text: Lotta Fredholm, first published in Medicisk Vetenskap nr 3/2019.
Photo: Joel Nilsson