The birth of a baby is one of life's happiest and most celebrated moments. But for an alarming number of Australian woman childbirth can also lead to physical and psychological injuries that have a devastating impact on their ability to enjoy life post-birth.

In fact, in Australia, one in three women describe their birth as traumatic, and 10 to 20 per cent of first-time mothers experience a physical birth injury that impacts their long-term health. Further, 5 per cent of women having a first vaginal birth will experience a third of fourth-degree perennial tear, which is above the reported average in the OECD.

Fortunately, women's and pelvic health physiotherapists can help identify risk factors, deliver education and provide physical therapy before and after childbirth to help minimise birth injuries and trauma.

Sue Croft, a pelvic health physiotherapist and author, says a combination of assessing risk factors, exercises during pregnancy, management at birth, and physical therapy after delivery contributes to better outcomes for women.

"The evidence is strong that performing pelvic floor exercises during pregnancy will decrease the incidence of stress urinary incontinence."

While perineal massage (from 36 weeks) isn't supported by strong evidence, it's a simple intervention that is worthwhile, says Ms Croft.

"We see women who are keen to have a vaginal birth, sometimes weekly from 36 weeks, to do measurements and see how their perineal body length and pelvic floor muscle overactivity are improving with relaxation strategies.

"A device called an Epi-No, and perineal massage can enable women to successfully have a vaginal birth without pelvic floor trauma.

"We also have a few predictive factors about what can increase the risk of birth trauma, which can better inform women of any potential risks with a vaginal birth," says Ms Croft.

Predictive factors of risk with vaginal birth

Age of mother

Levator avulsion is strongly associated with the mother's age, explains Ms Croft, and incidence more than triples during the reproductive years from below 15 per cent when the mother is aged 20 years to over 50 per cent when aged 40 years.

"Delaying your family may therefore increase your risk of levator avulsion with a vaginal birth.

"So, if you are over 35 having your first baby, it may be important to discuss the mode of delivery with your obstetrician."

Use of forceps

Some studies show that 40 to 45 per cent of women who have a forceps delivery will suffer a partial or complete avulsion and a forceps delivery is a significant risk factor for faecal incontinence.  

"Discussing the option of a vacuum delivery versus forceps or forceps versus a caesarean birth with an obstetrician during pregnancy will help women make an informed decision in the labour ward."

Birth weight

A baby with a birth weight of over 4kg can increase the risk of anal sphincter tears.

Long second stage of labour (the pushing stage)

If the second stage of labour is prolonged, there is an increased risk of traction or compression injuries to the pudendal nerve and levator avulsion, says Ms Croft.

Baby's head circumference over 90th percentile at 38weeks

"[This] is something that can be checked with a scan, and the woman can make an informed decision about mode of delivery.

"[Have] a discussion regarding early induction of labour from 38 weeks if Estimated Foetal Weight or Head Circumference is above 90 per cent."

Other factors – UR-CHOICE

UR-CHOICE, a scoring system to predict the risk of future pelvic floor dysfunction based on research of significant risk factors, is an important way to assess risk, explains Ms Croft.

"This research has followed up women at 12 years and 20 years after delivery, and this scoring system together with the mother's preference, may help with counselling women regarding pelvic floor dysfunction prevention."

UR-CHOICE stands for:

U -   Urinary incontinence before pregnancy
R -   Race (ethnicity)
C -   Child. Bearing first child started at what age?
H -   Height. Mother’s height (if < 160cm)
O -   Overweight. Weight of mother, Body Mass Index
I -     Inheritance. Family history of PFD (mother and sister)
C -   Children. Number of children desired*
E -   Estimated foetal weight (baby weighing greater than 4kg).

*If caesarean deliveries are indicated, this is important due to an increased risk of placenta praevia and accreta with increased number of caesarean deliveries.

Treating birth injuries starts with education

Quality antenatal education is the first step to ensure all women are prepared for childbirth, says Ms Croft.

"Antenatal preparation, where women understand how to do the correct action of the pelvic floor muscles before birthing, is important, so there is no confusion after birth."

Women must treat childbirth in the same way as an athlete recovering from a sports injury, explains Ms Croft.

"Good advice about treating the birth injury [needs to be provided] with as much respect as a footballer or tennis player treats any injury they sustain.

"Women are often expected to go back to their full household duties and often care for a toddler without any respect for the extent of the injury that may have happened.

"It is important to understand that the muscles forming the vaginal opening have to undergo a degree of distension that would rupture any other skeletal muscle.

"The levator ani muscles are stretched by 1.5 to more than three times their normal length as the baby passes through, depending on the size of both baby and pelvic floor muscle opening."

Pelvic floor physiotherapists also teach:

• Good bladder habits; the correct position for emptying the bladder; bracing with increases in intra-abdominal pressure (IAP)-also known as the knack.

• Good bowel habits; defaecation dynamics and the correct position for emptying the bowel; healthy eating, bowel products as required; no straining at stool.

• The values of a pessary: Does the patient need a pessary fitted to give support to the lax vaginal walls and the pelvic organs?

• Modify exercises appropriately to the individual woman's pelvic floor needs. If there is a significant avulsion injury, some exercises may need to be changed.

Physiotherapy critical after all modes of delivery

Whether a woman has an uncomplicated vaginal or Caesarean birth or a traumatic vaginal birth with multiple complications, pelvic health physiotherapy should be integrated into post-birth care, explains Ms Croft.

"The woman has still undergone significant physical and emotional changes during the pregnancy, during the birth and afterwards, which should warrant and deserves expert help from a pelvic health physiotherapist.

"I believe, and the evidence tells us, that seeing a pelvic health physiotherapist should be mandatory regardless of the mode of delivery."

In doing so, women can avoid unnecessary surgery for urinary incontinence and prolapse, says Ms Croft, and return to the workplace sooner with better physical and psychological outcomes.

What are obvious signs of birth injury?

Women who have given birth should be aware of the following obvious signs of birth injury and seek the service of a pelvic health physiotherapist.

• Urinary or faecal urgency, frequency or leakage.
• DRAM (Diastasis of the Rectus Abdominus Muscles) - it is now realised that most women undergo some degree of abdominal separation during pregnancy, which can weaken the abdominal muscles and impact the recovery and return to exercise of the woman postnatally.
• Recurrent mastitis (some women's health physiotherapists treat mastitis)
• Lump or bulge at the vagina, vaginal drag, ache or heaviness (prolapse)
• Sexual dysfunction: pain with sexual intercourse, loss of libido, fear of intercourse, loss of sensation.
• Any musculoskeletal pain (such a pelvic girdle pain, low back, neck, thoracic spine pain).

Ashleigh Mason, physiotherapist and women's health educator, says a combination of education and a reality check is vital to reduce physical injuries and birth trauma.

"Women should be given information about the potential things that could happen during birth.

"Trauma results from a need not being met. Many women go into birth with a birth plan and expect that their birth will go according to that plan.

"[There could be a] lack of education from their health care professional about the possibilities and realities.

"Or that as a society, we aren't being told about what could go wrong because no one wants to talk about these taboo topics, and women expect that they will have a beautiful, positive experience."

A birth plan is important, but birth is unpredictable, and women need advice that prepares them for all possible outcomes, says Ms Mason.

"Women should be empowered with the knowledge of what could happen and be prepared for that if those situations do arise."

Birth trauma occurs when women feel out of control and underprepared to make educated decisions during the birth, adds Ms Mason.

"There's still a lot of shame attached to birth trauma, and to break that taboo and stigma, we need more education and more women sharing their stories and starting these sorts of conversations.

"Women need to know that they're not alone and that although these injuries are common, they're certainly not normal, and women don't have to suffer in silence. There is a lot that can be done."