Ladies, We Need To Talk - The cost of birth trauma

0:02This is an ABC podcast. Hey ladies, a heads up. This episode is about birth trauma and some of the stories you're about to hear describe pretty full on physical injuries and mental trauma. So look after yourselves. Well you've got two choices. It's a colostomy bag or death.

0:26It makes life a misery. Imagine being incontinent of urine and feces or having constant pelvic pain because your uterus is on the outside of your body. Stop complaining. Millions of women do it every day. It's not that big a deal. It almost felt like you were jumping and nothing was in place. Then you felt like everything was just gonna come out between your legs. I didn't even know how to explain to people the darkness.

0:56I was feeling on a daily basis, the loneliness. Giving birth is technicolor. For the parents involved, it is a pivotal moment in their personal history, scrawled on the soul and etched on the heart. Things happen in that process that you never forget. I've done it four times. Four. And I can tell you from experience that a couple of things happen that we really should acknowledge. One is that it is such a momentous occasion that little things can seem huge.

1:29For instance, my ex overheard the midwife complaining about me, and then he told me, which was dumb, but for years afterwards, I felt a crushing sense of failure because I'd been annoying while giving birth, for years. Two, in the lead-up to giving birth, you're centre stage. The doctors want to see you, you're being weighed, measured, loved, protected. Then the minute the baby comes out, the spotlight shifts off you and onto the baby and you become...

1:58a bit of an afterthought. It's a dramatic and profound upstaging where you go from being the most important person in the room to a bit player. Now take those two things and add that to a birth where it didn't all go to plan. One in three Australian women describe their birth experience as traumatic and sometimes you can see it in the eyes of a new mother.

2:25Giving birth was less about halos of love and saintly, milky motherhood, and actually an experience of extreme violence. I'm Umi Steins. Ladies, we need to talk about birth trauma. A baby is born every minute and 43 seconds in Australia. In other words, all the time. Women have delivered under much worse conditions than we do for millennia.

3:07And having done it myself, I can tell you that just because it happens a lot doesn't mean that giving birth isn't a uniquely gruelling physical and mental experience. Now, we talked to a lot of people for this episode about their experiences of giving birth and its aftermath. And what we found is that birth trauma is so personal and varied. People who have had a relatively straightforward delivery can walk away feeling emotionally traumatised.

3:36and some women who suffer horrific physical injuries can feel like they're okay. Congratulations on your birth again. So, you're here for your post-partum checkup? Yeah. So, I'll pop the bed up. So, what we're going to do is start with just an observation on the outside, okay? Yep, okay. So, can you just do a little pelvic floor contraction for me, thanks Allie. Great. And then relax back down again. Good.

4:15Now what I'm going to do is just place this little pop stitch. This is Sophie Carroll, a women's health physiotherapist. Her patient Allie is lying on a massage table. Her lower half is covered in a pink gingham sheet. Allie gave birth to her third baby just nine weeks ago and Sophie's job is to essentially assess the damage. Now Allie, can you give me a big cough?

4:38Allie has kindly allowed the ladies we need to talk team to come along to a very private appointment. Now what I'm going to do is just insert one finger into your vagina. From here what I'm doing is just palpating around your superficial muscles. How does that feel there?

4:58A little bit soft. Now what I'm doing is palpating my finger on the front wall, so the anterior wall of your vagina. So what I'll get you to do now is another deep breath in. Hold the breath in and then I'd like you to bear down. I can just feel that front wall coming down just a little bit more than normal. And I would actually call that the stage one prolapse.

5:20Allie had her first baby Hudson at 25. So after Hudson I had fecal staining and fecal incontinence and I still didn't realise until years later that that was from Hudson's birth. I never put those two things together. The little guy had some health complications during pregnancy so the doctors wanted to deliver him a bit early. So he was induced at 38 weeks and I had two apesianomies and a four slips delivery.

5:51with him and then he was taken to NICU. With a sick baby, Allie wasn't too focused on herself at that point. But the injuries she'd sustained during the birth started to make themselves known soon after her epidural wore off. I remember standing in NICU and I'd gone outside to cough because I couldn't cough in front of all the babies and standing in a puddle and I didn't know where the puddle had come from. I had no idea.

6:20I had no sensation, no feeling, until I realised that it was my own urine. Allie had a few appointments with a women's health physio at the hospital, but after six months of treatment, there was only mild improvement in her continence. She thought it was just going to be like that. She was too embarrassed to tell her husband that at 25, she was incontinent. Then there were other issues that she found out about after the birth of her second child two years later.

6:52I had quite severe nerve damage. I don't have any nerve feelings anymore, so I can't orgasm anymore. Ever again. No orgasms from doing something that women do every day. After her daughter was born, Allie finally felt brave enough to tell her husband that she was wetting her pants and she got help. She saw about five different types of health professionals. And when I went...

7:21back to the colorectal specialist to discuss my results. He said that nerve damage usually takes two years to repair, and by that time it had been close to four years. So there was little chance of it repairing. Both sides of my pelvic floor had been ripped off the bone during Hudson's delivery, which I had no idea about.

7:41Silly me thought that it could just be repaired, you know, it might be in operation or it might be expensive But you know surely they could just reattach it and I came back to Sophie for my follow-up appointment and she said no it doesn't reattach and I thought oh, it's just gonna be flapping in the wind forever This flapping in the wind Ali is talking about is her pelvic floor muscle. It's no longer attached to either side of her pelvic bone The muscle can be ripped from either one or both sides. This birth injury is known by the term levata evulsion. If you were to put your fingers just above your vagina, you'll feel the bone that's sort of right there. That is your pubic bone, the one just above where, you know, your legs meet. Dr. Jessica Cordwell Hall is an obstetrician and gynecologist with a PhD in birth trauma. That bone is where the

8:42muscle attaches. So if you think about that bone as a roof on a house, the muscle comes down, it attaches at the top of the pubic bone, comes down all the way down the side of the vagina under the anus and back up like a U-shaped loop, a sling almost. And it is that sling that holds everything tightly closed. Now when the baby's head comes down and out during a vaginal delivery for probably one in ten women, that muscle tears and when it tears it's no longer attached to anything so you can do pelvic floor muscle exercises and things like that and you will train up the other muscles of the pelvic floor but you can't train that muscle up anymore it's not attached. So that's a levata evolution but let's back up a bit. What is birth trauma?

9:35So it's a very broad term that can refer to either the emotional or the physical damage that someone sustains while giving birth. And it's interesting because it's very individual to the woman. What I might think of as a perfectly straightforward grade A, everything went perfectly. Simple vaginal delivery can actually leave someone terrified of birth down the track. Dr. Jessica, can you?

10:02talk me through what is happening to a woman's body during a vaginal birth. With a vaginal delivery you have three stages of labor effectively. So the first stage you have uterine contractions and the idea is that you get this explosive force that is pushing the baby down and out of the birth canal. So when the fetus comes down and hits the pelvic floor there's rotation and then the head exits the body followed by the rest of the baby effectively. Where we are finding that damage is being done is that as the fetal head exits the mother's body you get damage to the pelvic floor muscles and the surrounding tissues.

10:48essentially you have to have a stretching of the pelvic floor but in some cases if it doesn't stretch it tears and when those tears occur they can be superficial say a first or a second degree perineal tear or you can have more serious tears where you get things like a levator avulsion or you can have obstetric anal sphincter injury where the anal sphincters, so you have an external anal sphincter and an internal anal sphincter, they tear. So more commonly you get the external anal sphincter that tears, but you can tear completely through both sphincters and that's termed a fourth degree tear. Right, a fourth degree tear. Yeah. Basically, so I'm cupping my hands and it's a tear down there. A tear down there. Yeah, that's pretty much a good way to put it. I'm pulling my hands apart.

11:36Yeah, look, how I would describe it is that if you were looking at yourself with a mirror, it is a tear that goes from the bottom of your vagina through to your anus. So the two are sort of no longer separate. Right. So now you have basically one orifice down there. You get women who have long-term problems from tears like that. If you get that traumatic tear, and most women get a tear on the right side. Really unlucky ones get a tear on both sides. If that happens, what happens then is that the opening of the vagina widens over time and eventually the pelvic organs will fall through that opening. So you have a risk of prolapse that's associated with these sorts of tears. Australia has the highest rate of third and fourth degree perineal tears in the OECD.

12:30Dr Jessica attributes some of that to the diagnosis. We are just getting better at finding them. The other thing I think is impacting on that is that we are seeing a rise, especially in New South Wales, in the rates of forceps. So if you use forceps to facilitate vaginal delivery, your rates for obstetrics, sphincter injury, levator evulsion, urinary incontinence.

12:57anal incontinence, they all go up drastically compared with the rates for a simple vaginal delivery and even more drastically compared with elective cesarean section. What happens in a forceps delivery? I can't picture it. So they're like a big clamp that in you put it on the baby's head. I like to think of them as salad tongs and they're designed to fit around the baby's head. They can be very effective if there is and say if you've got fetal distress and you've got a very sick baby and you need to get them out very quickly they generate a significant amount of force very quickly because when I pull they are metal they just tend to tear tissue it's the fact that the head is coming out across the pelvic floor with force and

13:41quickly. There's no time to stretch. So it just snaps. Yeah, I know. And you can hear it. It sounds awful, but sometimes when you deliver, you can feel a pop and you know when it happens. I'm like, oh goodness, there it is. Yeah, it's awful. Basically, I was torn internally up to my bow. I ended up with a fourth degree fistula.

14:09An obstetric fistula is a hole between the birth canal and the bladder or rectum, and it's something we usually associate with women giving birth in developing countries. In Nicola's case, her rectum and vagina were no longer two separate passages after birth. But her injuries weren't discovered right away. In fact, the obstetrician was praising the delivery as pretty successful. I was induced.

14:36The obstetrician said that seven millimetres dilation had stayed too long so we're going to put a spinal block in and get her down for an emergency caesarean. So basically I got the spinal block and then I was rushed downstairs and then as I got downstairs in the five minutes I dilated the three centimetres so they said you can do it naturally and of course you go of course.

15:03And I did and he was extremely happy with the delivery, the obstetrician. So hang on a sec, so you delivered your daughter? Yeah, delivered my daughter naturally. So was there any indication sort of as the process was completed that something had gone wrong? No. He actually gave the other people in the theatre a high five for delivering the baby so quick. Okay. Wow. Yep. It was I thought it was great. He said there was only one and a half stitches involved. And we eventually found out through massive internal urology that it was through a fourth-degree tear that was not diagnosed at birth. You're kidding. No. So the rectal exam could have prevented that and then that could have been fixed at the time. In the days after the birth, it was actually Nicola's mum who twigged that something wasn't right.

16:02About two days after I gave birth, my mother came to the door and noticed quite a pungent smell. And I said, mum, that's me. And she said, show me the maternity pad. There was actually no blood on it. Later down the track, we actually found out I was actually starting to rot because I had turned septic. So what was happening was my fecal matter was coming down through the bowel and when I was going to the toilet, what was coming out was actually fecal matter. What was happening, and this is graphic, is poo was coming out of Nicola's vagina. In the next 24 hours, Nicola was rushed into surgery to repair the hole between her bowel and vagina. When she woke up, Nicola realised things did not go to plan. I heard a pop and basically the operation had been a

17:01had been a failure. So it had now turned from one centimetre to over an inch and a half. So if you go up through your anus and go finger size of your index finger, there was now an inch hole between that and the vaginal wall and the bowel and the colon, etc. So the professor of the private hospital came to my bed and said, Well, you've got two choices. It's a colostomy bag or death. There's no choice there. Basically, the Stoma nurse came in at 9am when she started, got out her Sharpie and said, where do you want the hole? And drew on me like I was basically a dead body. And I'm just in shock. I've just given birth. Nicola lived with a colostomy bag for two years. It was just constant pain.

17:59the entire time like you know and a therapist later on said you basically were awake for a nightmare for over two years. I didn't even know how to explain to people the darkness. I was feeling on a daily basis the um the loneliness because I didn't know anybody with a stoma with a colostomy bag.

18:21After eight or nine surgeries, including one to replace her pelvic floor with a muscle cut from her thigh, Nicola considers herself pretty much recovered in a physical sense, but the emotional scars remain. I don't know who I was. I couldn't identify with others. It was just awful. When people keep telling you, you're beautiful, you know, your daughter's beautiful, you're amazing, you're so strong, It takes away the fact that you're day by day, minute by minute, you're just surviving. And that's how I ended up with PTSD five years later. The lack of me even talking about it, it was so taboo. The most natural thing on the planet is to have a child. Yet we don't talk about it. We sweep everything under the carpet and say, yeah, everything's fabulous when legitimately it is definitely not.

19:22When we try and talk about these things people say well all that matters is that you had a healthy baby or my favorite will stop complaining millions of women do it every day It's not that big a deal Righta Clementine Ford is trying to break the taboo around birth trauma She's very open about her experiences and discusses it with women on her large social media network. I think that in general women talking about our trauma is not There's not necessarily a lot of space for that. Women in particular are expected just to grin and bear it. Everyone just wants to think about this beautiful cherubic baby with their soft skin and their chubby cheeks. They don't want to think about the fact that while you're holding the baby, your bladder might be poking out of your body or you might be wearing fecal incontinence pads.

20:20Clementine's now five-year-old son had to be induced after being 16 days overdue. Seven hours after they put the drip in, they checked my dilation and I dilated half a centimetre. So, and by that stage, I think it was like about three centimetres dilated. And I just remember feeling like the most crushing kind of defeat. Just... Sorry. It's so weird when you talk about it and you think, you're fine, you know. And I am actually fine. I'm fine.

20:55But it's just, it just taps into those little pockets of trauma, doesn't it? Sorry. Anyway, eventually, you know, I got the epidural. I was suddenly in, you know, I had that pain relief. So I felt like, well, I can go for a little bit longer. And then, you know, around nine o'clock the next morning. So by this stage, I'd been in labor for, you know, 15 hours.

21:23So I started pushing and of course none of us know how to fucking do it. And they were like, you're doing it wrong. And they were very nice about it. So I pushed the baby out, took me an hour, obviously put a huge amount of stress on my pelvic floor, which then manifested in a lot of problems over the next few years. And when the baby came out, he was covered in meconium.

21:47There's a fear that they may have aspirated some feces and that's very, very dangerous, particularly for newborns. The baby was in distress and Clementine started to hemorrhage. There were doctors and midwives rushing in and out. It was a hectic scene. Everyone was freaking out. I remember my son's dad at the time was like, you're covered in blood, the baby's over on the table and I thought both of you were going to die.

22:12You know, even describing that now, I have that tendency that we have to be like, it's not it's not as bad as other people's. You know, it wasn't that bad. You know, I didn't die. I didn't suffer like catastrophic prolapse or, you know, a fourth degree tear or anything that causes huge amounts of problems for people later on. But yeah, I think that I just filed it away. When was the realisation that you suffered trauma during the birth? When did that occur to you?

22:40You know, I don't think that there's a particular moment where you wake up one day and you go, oh, I think I might have a little bit of PTSD from that. It's one of those things that kind of unfolds, isn't it? You know, I went through the birth and then you're just in survival mode. It's like falling asleep. You know, it sort of happens slowly and then all at once. Aside from the mental trauma.

23:05Clementine, along with a third of all new mothers, experienced urinary incontinence after giving birth. I wore incontinence pads for the first eight months of my baby's life because I had issues with bladder control. My pelvic floor was so stuffed that I was just leaking everywhere. I felt so much shame and I was frantically googling.

23:32day in and day out, you know, in addition to how do I make my baby sleep, I was googling fixed pelvic floor, things to fix pelvic floor, how to stop peeing yourself after birth, all of these things. And terrified really that this would be my life now, from now on. Clem raised her incontinence with health professionals and their solution was to hand her a pamphlet called One in Three Women Wet Themselves After Birth.

24:00Weirdly, Clementine wasn't reassured. Possibly something to do with the title. And she took matters into her own hands. I feel the urge to say that I have thankfully recovered. I did a treatment that involved electromagnetic therapy that electrically stimulated my pelvic floor, which restored it to a lot of its former function. I think what helped me was that I never worried.

24:27I must have known on some level that if I needed to seek help, I would be able to do that. That I had people I could talk to. Whereas I think that, you know, for other people, they do worry that if they talk about these things that they'll be surrounded by, even in their own family, by people who tell them, you know, well, all that matters is that the baby's fine.

24:54I did feel like I failed because the obstetrician had told me. She didn't know how to help me, that I had failed the process. This is Kishala. She's still dealing with the trauma of how she was spoken to during the labour of her second baby. When I got into the stage of my labour, where it was obviously stalled, but I was very much in pain and at that point...

25:21I was screaming and saying, I need this baby out. And the obstetrician came in and sort of screamed at me and said, I don't know how to help you. You have to stop screaming. I don't know what to do. You tell me what to do. And I just kind of felt silent. And then I said, the only way is emergency caesarean. But it was that moment that is so vivid and probably took in my head. It takes up a large proportion of.

25:50what my labour was. Kishala's petite and she had two big babies, around four and a half kilos each. She didn't discover her physical injuries, which were a levada evulsion and a prolapse, until her eldest child was six years old. She first noticed something wasn't right when she was skipping one day. It almost felt like you were jumping and nothing was in place. Like every part of the inside of you was...

26:17not hanging on and you felt like everything was just going to come out between your legs and you're going you're just skipping like how can this possibly be. I've seen many pelvic floor physios now and they all kind of said to me the same thing which is this is a normal part of your birth process. You've had two big children, you're quite petite yourself and so this is this is the way that it's going to be. You just have to learn to live with it.

26:42When is someone going to tell me I don't have to live with pain or I don't have to live with my injuries that impact me on a daily basis? I'm a first generation Sri Lankan in Australia. When I heard about my birth injuries, I spoke to my mum that was my first point of call and I said, hey, have you heard about this? How did your births go and do you have any injuries?

27:08Kishala says the women in her family and community just did not have those conversations about vaginas, pelvic floors or birth trauma. It's so taboo it's like it doesn't exist. It's not common in our culture to go see a gynecologist. And that was when we started to dig in and talk to other women and in our friend circles in our community that we realised that we don't really see a gynecologist. We don't check out.

27:37our health before we give birth or from an earlier age with some cultures, they do do that. There are so few stories of women from my culture, social relinquents, Southeast Asian women who want to talk about their birth stories. It is so important for us to share and especially for our children that come after us to make sure that they don't have to go through this trauma like we did.

28:08What I would like you to do is imagine that your vagina is a lift shaft. What you're going to do is take a nice, slow, deep breath in, breathe the air all the way back out again. The end of the exhalation, I want you to think about closing the lift door so you can squeeze those muscles around my finger and take the lift to level one. Then you're just going to do some normal breaths, take the lift to level two, then level three, then back down to level two, level one.

28:37and then ground floor. We're back in the room with Allie, who's given birth three times, and women's health physio Sophie, who's assessing Allie's pelvic floor. Allie experienced a bilateral levada evulsion, which means her pelvic floor muscles have been ripped from both sides of the pelvic bone and irreparable nerve damage that means she can't orgasm anymore.

29:02I want to know if there's hope for Allie and other women like her who have suffered similar injuries in childbirth. I've been waiting for my appointment with Sophie to know how I'm going to get better. So now that I'm started, I know that my public health will improve. It's only been nine weeks since your birth. You know, it will take time as well. In time, things will heal.

29:30and your pelvic floor will actually get stronger as well, okay? But we just kind of like to speed it up a little bit and give it a little helping hand and give you some pelvic floor exercises to do. See you in three weeks. Yes, yeah. Lovely to see you and welcome Flynn. I'll see you in three weeks. Thanks, Ellie. Bye. Hey, remember I said a baby is born every one minute and 43 seconds in Australia? Well, since you've been listening to this episode of Ladies We Need To Talk, around 21 babies have arrived.

30:01I mean, I look at women and I think, oh my gosh, I'm constantly amazed at how brave and strong and, you know, committed to being a mother they are. Dr. Jessica Caldwell Hall again. In an ideal world, someone has this beautiful labor and delivery. They have a beautiful birth that they're proud of and they walk away and everyone's happy. You know, it doesn't always work out that way.

30:25But I certainly think that, you know, no woman should walk away from her birth feeling like she failed. If you brought a human being headfirst into the world via whatever portion of your body, you should be proud of yourself. Hear that, ladies? Be bloody proud of yourself. What you've achieved is superhuman. And guess what? It is also OK to not be OK. I think in general women have a right to be just as healthy and whole as they want to be. I mean, we're 50% of the society for heaven's sakes. Imagine if men had, you know, some organ prolapse out of their body and everyone just shrugged and said, oh, well, get over it. That's just what it is to be a man. See ya. I mean, it just, you know, it just wouldn't fly. If you're struggling with how your birth went or your mental health isn't great, your body doesn't feel quite right. If you're in pain or peeing every time you cough,

31:25There are specialists who will know what you need and how to help. They do exist. Start with your GP. A pelvic floor physio isn't nearly as exotic or hard to find as you think and talk to your friends. Who knows, they might be going through something similar. And the Australian Birth Trauma Association has some really great resources. And remember ladies, as the good doctor says, you are doing everything right.

31:54you are doing everything right. Ladies is mixed by Anne-Marie DePettancourt, who does our sound so right. It is produced by Tamar Kranzwick, a producer who's producing is pretty awesome. Supervising producer is Alex Lollback, who is occasionally slightly cool sometimes. And our executive producer is Justine Kelly, who does EPing like a boss. This series was created by the very excellent Claudine Ryan. My name's Yumi Steins. Thanks so much for listening. If you'd like to email us, ladies at abc.net.au is our email.

32:26address and don't forget to tell your friends to listen to this. It is called Ladies We Need to Talk. This podcast was produced on the lands of the terrible Yugungbe, Gurungara and Gadigal peoples. Ladies, if some of the peeing yourself stuff that we mentioned in this episode resonated or sounded a little familiar to you, go back in your Ladies We Need to Talk feed because we've got an episode called The Pelvic Flaw in All of Us.

32:59we all have a little bit of weakness there. My vagina isn't the same as it was when I was 20 years old. And do I care? No, because my face isn't either. My boobs aren't either. Everything changes. Get it, pelvic floor? Floor? It's got some really great tips on how to keep our pelvic floors in shape and get us back to our old selves after childbirth.