When I told people that I had many childbirth complications, most of them assumed I’d had a C-section—and were shocked when I said I hadn’t. The risks of C-sections are generally well understood: infection and hemorrhage, among others. Yet people’s—including expectant mothers’—understanding of the risks of vaginal birth is greatly lacking. I was severely injured during vaginal childbirth, and my injury was not taken seriously by healthcare providers.
Then there are situations like mine, where the pressure to avoid a C-section leads to a traumatic, devastating experience.
Ninety percent of women giving birth vaginally suffer tearing of their vaginal skin and/or pelvic floor muscles, which, in many cases, leads to ongoing pain, urinary incontinence, or fecal incontinence. The stretching and tearing of the pelvic floor muscles can also cause prolapse, a life-changing condition in which the bladder, uterus, or rectum drops down into the vagina. Both incontinence and prolapse can occur shortly after vaginal delivery, or they can appear much later in a woman’s life, as the aging process further weakens her pelvic floor muscles. In the last decade, there has been a major push to decrease C-section rates. Then there are situations like mine, where the pressure to avoid a C-section leads to a traumatic, devastating experience.
I had a forceps delivery—likely an effort by the obstetrician (and hospital at large) to keep one more woman’s body from adding to that pesky C-section rate. Instrument-assisted deliveries, including forceps, are rare these days, falling out of favor because they have been shown to increase the risk of maternal morbidity. But some data suggests that their use is actually once again on the rise. Due to the forceps, I got a near-fourth-degree laceration, a devastating injury that has a complicated healing process and, in some cases, leads to permanent bodily dysfunction.
A fourth-degree laceration occurs when, in the process of a vaginal birth, the vaginal skin, perineal muscles, anal sphincter, and rectum all tear. A third-degree laceration affects part or all of the sphincter but spares the rectum. (I was just shy of tearing through my rectum.) A second-degree laceration affects the vaginal skin and perineal muscles, and a first-degree laceration affects only the vaginal skin. Third and fourth-degree tears are rarely spoken about, but when they are, they’re sometimes brushed off as funny and unbelievable. But there is nothing funny about them. There is also nothing unbelievable about them. The CDC indicates that around 1 percent of women giving birth in 2018 ended up with fourth-degree tears and 3 percent with third-degree tears, but there is evidence that such data is underreported, with OBs and midwives sometimes missing the tears. Some studies put the occurrence rate of third- and fourth-degree tears as high as 11 percent, while others suggest that more than one out of every three women giving birth vaginally has some damage to her anal sphincter. The deep and pervasive silence surrounding this injury seems impossible. Yet it exists.
Third and fourth-degree tears are rarely spoken about, but when they are, they’re sometimes brushed off as funny and unbelievable. But there is nothing funny about them.
There are women who endure severe tears, have adequate repairs immediately after birth, and heal without further problems. But many do not. Approximately 25 percent of women who suffer severe tears end up with wound infections. Some of these infections can be managed with antibiotics alone, but some are so severe that they cause a complete breakdown of the initial repair. This is what happened to me.
Shortly after returning home from the hospital—where, upon discharge, my stitches were not examined—I grew concerned that something was wrong. After multiple calls to two on-call OBs—who both implied I was overreacting—I decided to leave my several-day-old baby with my husband and go to the ER. I was promptly diagnosed with an infection, readmitted, hooked up to intravenous antibiotics, and informed by urogynecologists that I would need corrective surgery for my near-fourth-degree tear.
What?
I had no idea what a third- or fourth-degree tear was, let alone that I had one. I knew, of course, that I had experienced some tearing during birth, but no one had told me the extent. Why was I only just hearing about this now—after I had gone to prenatal appointments for nine months, after I had given birth and been badly injured, after I had been discharged, after I had made the decision myself to go back to the hospital? Also, why did the OB, knowing the increased risks, encourage her resident to use forceps on me, after hours of fruitless pushing—and not encourage a C-section, which, if encouraged earlier on, likely would have had far fewer complications?
There is a lot of well-intentioned focus now on honoring women’s choices in childbirth. Who, though, is responsible for providing education so that women can make those choices in an informed manner? Healthcare in the United States is a business, and, like many of today’s businesses, it is rapidly moving toward a self-service model. While this may work for some wealthy pregnant women who can afford additional, out-of-pocket guidance, the majority of pregnant women in this country need thorough and unbiased information from healthcare providers—before they’re in the delivery room.
We’re often blinded by cultural ideas about what is the “natural” or “right” way to give birth. In movies, a woman’s water breaks, there’s a mad dash to the hospital, she pushes the baby out, then holds her new bundle, sweaty but smiling. A woman wheeled into the OR, her abdomen sliced open, doesn’t figure nicely into that image.
I had no idea what a third- or fourth-degree tear was, let alone that I had one
Here’s what also doesn’t figure nicely into that image but can be equally true: a woman’s vagina after giving birth, swollen, bloody, ripped, and sewn back together. A woman’s anus, also ripped and sewn back together. A broken tailbone. A wound infection. All of these things, and more, can result from vaginal birth—and the risk of complications rises if the birth is instrument-assisted. Yet expectant mothers are terribly undereducated about these risks—often until they experience them personally.
Without promptly going back to the hospital, my infection would have likely progressed. Untreated infections can cause sepsis—a life-threatening condition from which about 40 percent of those affected die. As it was, I ended up taking antibiotics for over a month. My healing from the corrective surgery was not smooth either—for weeks, part of my wound had to be packed with gauze.
But I survived, and today, you would not know from looking at me that anything terrible happened. Physically, I feel 90 percent normal now—although, psychologically, I will never be whole again. I desperately wish I had been informed of the risks of forceps, and of vaginal birth in general. I desperately wish I had been presented with the benefits and risks of both vaginal and C-section deliveries in advance, and that an elective C-section had been discussed with me as an option. Women deserve to know that vaginal births come with risks, too. The longer we are misinformed, the more devastating our outcomes will be.
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