What is birth injury?

Birth injuries are physical injuries experienced during childbirth. They can affect either the mother or the baby. In newborn babies, a birth injury (also called 'neonatal birth trauma') can include a range of things, from minor bruising to a broken bone.

If you've given birth, injuries may range from tearing in the vaginal area to pelvic floor damage to pelvic fractures (rarely). Caesarean wounds can also be considered a physical birth injury.

Physical injuries due to birth injury typically need assessment and treatment by a trained health professional.

Birth injuries in mothers typically fall into 2 main categories:

• injuries to the perineal area
• injuries to the pelvic floor

Injuries to the perineal area

• Perineal tears and episiotomy — around 3 in 4 females who give birth vaginally experience 'perineal trauma'. This refers to a tear or surgical cut to the perineum — the area between the vagina and anus. A perineal tear may involve the:
  • skin of the perineum or labia (first-degree)
  • muscles of the perineum (second-degree, which is most similar to the depth of an episiotomy)
  • muscles controlling the anus and bowel movements (third-degree)
  • lining of the anus (fourth-degree)
• Nerve damage — occasionally, nerves in the perineal area can get damaged during childbirth, which can lead to a condition called pudendal neuralgia (long-term pelvic pain). You may experience pain around the vagina and perineum and sometimes down the legs. Bowel or bladder irritation, or a fullness sensation in the vagina or rectum can also occur.
• Obstetric fistula — this is a rare complication in Australia. This refers to a tear between the vagina and the bowel which causes an inability to control the passage of faeces (poo). It occurs when a third- or fourth-degree perineal tear high up the vagina goes through to the rectum (called a 'buttonhole tear') or if a perineal tear is deep, is not repaired well or an infection occurs.

Injuries to the pelvic floor

• Muscle damage — the 'pelvic floor' is a group of muscles inside the pelvis that helps hold the uterus, bladder and bowel in place. Many people who give birth vaginally have long-term changes to the pelvic floor due to over-stretching or tearing (avulsion).
• Pelvic organ prolapse — if the pelvic muscles are damaged or weakened, the organs inside the pelvis can drop down towards the vagina, causing bladder and bowel problems.

Symptoms of birth injury

Don't be afraid to ask questions as you may be the first to notice that something is not right.

Physical symptoms of birth injury may include:

• sweating, shaking, headaches, dizziness or gastrointestinal upsets
• continued pain after birth at the site of the tear or episiotomy (between vagina and anus)
• leaking or incontinence (problems with wee, poo or flatulence (gas))
• difficulty emptying bowels (problems with pooing)
• pain or difficulty having sex
• lower back pain

You may also notice a physical change to your vagina, such as:

• a bulge or lump at the vaginal opening
• a dragging feeling or as if something is 'falling out' — especially when you stand, lift, are tired or during your period
• a looseness of the vaginal or pelvic floor muscle

Can physical birth injury affect me emotionally?

You may find the experience of childbirth emotionally traumatic, even if there was no physical trauma. If your birth experience felt traumatic to you, then it was. Your experience is valid and worthy of acknowledgement, treatment and recovery.

You may notice symptoms of postnatal depression and/or anxiety, postpartum post-traumatic stress disorder or obsessive compulsive disorder.

Sometimes the effects of birth trauma might first appear some time after you've given birth. Birth trauma can continue long after the birth and some people may not recognise the signs for months or even years.

If you are concerned, it’s important to seek help from your doctor, midwife or child health nurse. Getting early care and support can help. It’s never too late to ask for help — some people seek help months or years after a traumatic birth.

There are many resources and professionals who can support your treatment and recovery from both physical birth injury and birth trauma.

What are risk factors for birth injury?

If you have a physical birth injury, the cause was most likely out of your control. Different birth injuries have different risk factors.

Some of the risk factors for birth injury can include:

• having your first baby
• being older when you have your first baby
• the length of labour or complications in labour
• having an assisted delivery using forceps or ventouse (vacuum)
• having a previous third- or fourth-degree perineal tear
• if you are of Southeast Asian background

Other risk factors may relate to the size or position of your baby at birth:

• if your baby has its back to your back (known as posterior presentation)
• having a baby estimated to weigh over 4kg
• if your baby experiences shoulder dystocia (when one of your baby’s shoulders gets stuck behind your pubic bone)

Can birth injury be prevented?

It's often not possible to prevent physical birth injury, and having a birth injury is never your fault.

There are things you can try during pregnancy and labour to help reduce your chance of serious physical injury when birthing your baby.

• Strengthen your pelvic muscles with daily pelvic floor exercises and avoid constipation which causes straining and can weaken your pelvic floor.
• Perineal massage from 35 weeks pregnancy can reduce the risk of perineal tears and reduce the likelihood of needing an episiotomy.
• Ask your midwife to apply warm compresses to your perineum during the second stage of labour to help stretch the area to allow for the baby's head.
• Use breathing techniques during second stage of labour, and stay active by moving around the room to encourage a slow controlled birth.
• Your doctor may recommend an episiotomy if you need an assisted birth. This will only be done with your verbal informed consent.
• After a vaginal birth, your doctor or midwife will offer to assess your vagina and perineal area for tears. This may also include examination by carefully inserting a finger in your bottom (rectal or PR examination) to check for internal tears.

Giving birth by caesarean could prevent some birth injuries, but it is a major surgery and carries its own risks.

Carrying a pregnancy, regardless of how you give birth, puts strain on your pelvic floor and can cause pelvic floor injury. You will make decisions about your birth as part of a shared decision-making process between you and your doctor or midwife. Unless it is an emergency, your health team should provide you with an explanation of any intervention, as well as the risks and benefits to you and your baby, before you can give your informed consent.

Consider creating a birth plan and getting tips on preparing for labour and birth. Your birth plan is a written summary of your preferences for when you are in labour and giving birth. You can also share your birth plan with your health team, and speak to your midwife or doctor about which birth positions you'd prefer to try. Depending on your situation and your preferences, your birth plan may include things such as a request for a warm perineal compress, help with breathing techniques or active labour.

How is birth injury treated?

Some physical birth injuries are minor and may heal on their own — for example, a minor perineal tear or graze. Other injuries need treatment at the time, such as a deeper tear that needs stitches. You may also need some pain relief. Let your health team know if you are in pain.

If you had a significant tear or damage to the muscles of the pelvic floor, treatment may include physiotherapy and exercises to strengthen your pelvic floor muscles. Vaginal pessaries can be used to manage a prolapse, or surgery can be used to repair it.

Some women may need to use pessaries in their vagina or surgery to repair a prolapse. Sometimes, signs of pelvic floor damage or prolapse are not detected and treated until much later.

What can help my recovery?

The best way to help your recovery will depend on the type of injury you have.

If you have a third- or fourth-degree perineal tear, your doctor will usually prescribe antibiotics to reduce the chance of your wound becoming infected. Your doctor may also recommend pain relief medicines and stool softeners, so you don't need to strain to open your bowels (do a poo), which might stretch your wound.

When can I have sex again after birth?

When you start to have sex again is a personal decision. It might be some time before you want to have sex.

If you've had a serious birth injury, speak to your doctor about their recommendations. They will consider your specific circumstances. It's also important to let them know if you experience any ongoing pain or have any other concerns.

What follow-up appointments should I have?

Follow-up appointments with your doctor or midwife are important, especially as some symptoms can take time to settle down or show up. For example, they may want to see you a few weeks after birth and then again a few months later. Make sure you understand your follow up plan before you leave the hospital.

If you have had a birth injury, depending on the cause and severity of your injury, you may be at a higher risk of it happening again in a future pregnancy. Your doctor will talk to you about your options for your next birth.

Who can I speak to if I'm not satisfied with my healthcare?

If you aren’t satisfied with your healthcare, there are many people you can speak to, including:

• your doctor or midwife
• the health complaints agency or health department in your local state or territory
• the Australian Health Practitioner Regulation Agency (AHPRA), if you have a concern about the unsafe behaviour or practice of a registered health practitioner
• the National Health Practitioner Ombudsman

If you aren’t sure about something that happened to you, especially during labour, birth or in an emergency, it’s a good idea to ask your doctor or midwife for a debrief. This is an opportunity to ask questions after an event, so that you better understand what happened.

Some hospitals offer this as a formal service — ask your midwife or doctor about what is available.

You can also view your medical records on your own or with another health professional. Find out more about requesting access to your medical records from the Health Information Office of the Australian Information Commissioner.

Resources and support

• Speak to your doctor, midwife or obstetrician about your symptoms or any questions you have.
• Visit the Australasian Birth Trauma Association for information and support, including their peer2peer support programs.
• The Continence Foundation of Australia offers confidential information and support to people with bowel and bladder problems. Call the helpline on 1800 33 00 66 between 8am and 8pm (AEST), Monday to Friday excluding national public holidays.
• Visit PANDA (Perinatal Anxiety & Depression Australia) for information and support after a traumatic birth. You can call the PANDA national helpline on 1300 726 306 (Mon to Sat, 9am to 7.30pm AEST).