A Mumsnet discussion over the weekend (one of many on the subject) highlights the fact that too many women are not informed about the risk of pelvic floor damage.

Below are some examples of what’s been said by different women (my bold highlight), and there’s a definite theme of ‘no one told me this could happen‘.

  • I considered myself to be quite well informed and I’d never heard of it…”

  • When I was diagnosed, I had never heard of it and had no idea that my uterus, bladder, or bowel could fall. It affected my ability to go to the bathroom, i am physically active and I had to stop running, I had no libido and when I did have sex it hurt. When I talk about this to my female friends, they don’t know about it either.”

  • So many women do not know anything about this and it is life changing.”

  • I was 5 weeks postpartum with my first baby at the age of 30 when I discovered my prolapse. I had the ‘perfect’ birth too- easy, call water birth of an average sized baby. Turns out my prolapse is because of something called levator avulsion- my main pelvic floor muscles were torn off my pelvis when my daughter crowned. It’s a very common injury to some degree and it is never discussed in childbirth classes…Women need to be informed of the very real risks to their pelvic floor during childbirth. Prolapse is a debilitating condition, both physically and emotionally.”

  • It seems to be a hidden risk to childbirth that just isnt discussed enough.
  • It’s something that should be discussed more.
  • It happens to so many women, but yet so many are blissfully unaware of existence until it happens to them.
  • This is one of the reasons I had sections. Women need to be informed of ALL risks of childbirth and them be able to choose their method of delivery.
  • I was blissfully unaware of POP until a friend was diagnosed.
  • I suffered for 4 years after a forceps delivery, despite seeing my GP…She reassured me that all was fine…I’m a HV so in an ideal position to discuss this with women postnatally but have never (neither have my colleagues) had any training in it.
  • If it wasn’t for mn I might never have known that my problems weren’t “normal” following childbirth (as I was helpfully told by one gynae registrar…
  • It can’t always be avoided but I’d never heard of it before having my little one.
  • There is such total ignorance on the true costs of vaginal deliveries for so many women. I’d have sections planned now in a heartbeat, if I could go back in time.
  • I’m a healthcare professional and appalled by how ignorant I was about prolapse – and the risks I had inadvertently taken out of ignorance.
  • It is both wonderful and sad to read all of the responses. Wonderful that each of us knows we are not alone, sad that most of us have never heard of this.
  • For POP to remain shrouded in silence despite nearly 4000 years on medical record is absurd. Zero doubt POP awareness will generate the next significant shift in women’s health… The voices of women around the world will generate change!

Change is Coming

The 2015 Montgomery Supreme Court judgment made it clear that women need to be informed about the risks of different birth plans, regardless of whether they ultimately choose a caesarean birth or not:

“The relative importance attached by patients to quality as against length of life, or to physical appearance or bodily integrity as against the relief of pain, will vary from one patient to another. Countless other examples could be given of the ways in which the views or circumstances of an individual patient may affect their attitude towards a proposed form of treatment and the reasonable alternatives. The doctor cannot form an objective, “medical” view of these matters, and is therefore not in a position to take the “right” decision as a matter of clinical judgment.

“There is no question in this case of Dr McLellan’s being entitled to withhold information about the risk because its disclosure would be harmful to her patient’s health. Although her evidence indicates that it was her policy to withhold information about the risk of shoulder dystocia from her patients because they would otherwise request caesarean sections, the “therapeutic exception” is not intended to enable doctors to prevent their patients from taking an informed decision.

“Once a woman is pregnant, the foetus has somehow to be delivered. Leaving it inside her is not an option. The principal choice is between vaginal delivery and caesarean section. One is, of course, the normal and “natural” way of giving birth; the other used to be a way of saving the baby’s life at the expense of the mother’s. Now, the risks to both mother and child from a caesarean section are so low that the National Institute for Health and Clinical Excellence (NICE clinical guideline 132, [new 2011] [para]) clearly states that “For women requesting a CS, if after discussion and offer of support (including perinatal mental health support for women with anxiety about childbirth), a vaginal birth is still not an acceptable option, offer a planned CS”.

“That is not necessarily to say that the doctors have to volunteer the pros and cons of each option in every case, but they clearly should do so in any case where either the mother or the child is at heightened risk from a vaginal delivery. In this day and age, we are not only concerned about risks to the baby. We are equally, if not more, concerned about risks to the mother. And those include the risks associated with giving birth, as well as any after-effects.

“A patient is entitled to take into account her own values, her own assessment of the comparative merits of giving birth in the “natural” and traditional way and of giving birth by caesarean section, whatever medical opinion may say, alongside the medical evaluation of the risks to herself and her baby. She may place great value on giving birth in the natural way and be prepared to take the risks to herself and her baby which this entails. The medical profession must respect her choice, unless she lacks the legal capacity to decide (St George’s Healthcare NHS Trust v S [1999] Fam 26). There is no good reason why the same should not apply in reverse, if she is prepared to forgo the joys of natural childbirth in order to avoid some not insignificant risks to herself or her baby. She cannot force her doctor to offer treatment which he or she considers futile or inappropriate. But she is at least entitled to the information which will enable her to take a proper part in that decision.

“As NICE (2011) puts it, “Pregnant women should be offered evidence-based information and support to enable them to make informed decisions about their care and treatment” (para Gone are the days when it was thought that, on becoming pregnant, a woman lost, not only her capacity, but also her right to act as a genuinely autonomous human being.”

It’s worth noting here that the definition of ‘normal delivery’ includes “antenatal, delivery or postnatal complications (including for example postpartum haemorrhage, perineal tear, repair of perineal trauma, admission to SCBU or NICU.”

These risks are not acceptable to all women, ‘low risk’ or not.

Vaginal birth should be a well supported choice, absolutely, but it should no longer be a blind one.

  • Written by author and journalist Pauline Hull