The restrictions on fathers attending at maternity hospitals due to Covid-19 restrictions has once again highlighted how the needs and requirements of women while pregnant and giving birth are often overlooked, ignored and unheard. In Ireland conversations on the incidence and impact of maternal birth injuries has long been a taboo subject with generations of women suffering in silence.

Our David O’Malley recently participated in a panel discussion on the topic, speaking on the issues faced by his clients and how their interests could have been better served during labour and delivery. Public consciousness as to extent of woman affected by maternal birth injury in Ireland is exceptionally low. There are various risk factors for severe tears including the average age of the mother giving birth, large babies, and gestational diabetes. Instrumental delivery (use of forceps or a ventouse cup) is also a known factor which increases the risk of suffering a tear to the anal sphincter.

The implications of a severe tear are significant and life changing. These include severe pain, hypersensitivity, difficulty sitting, damage to the anal sphincter leading to bowel incontinence, damage to the pelvic floor and bladder incontinence. In many cases treatment involves reconstructive surgery and in some cases the fitting of either a temporary or permanent ileostomy or colostomy bag. From a psycho-social perspective perineal tears often result in a loss of self-esteem, reduced sexual function, and potential for psychiatric injury. The physical and mental effects of a vaginal and/or perineal tear in turn often has a profound effect on relationships and the ability to work. Relationships often disintegrate and woman are left feeling abandoned and traumatised. Perineal tears can lead to couples questioning their ability to have more children and entirely diminish libido.

A lack of open ante-natal communication between expectant mothers and health care providers has led to many new mothers not knowing what to expect during delivery, no clear discussion on modes of delivery and many women not having a clear sense of what is normal healing and recovery post-partum. It is therefore hugely important that the risks and benefits of all methods of delivery (including those with increased risks of suffering a tear) are adequately explained to pregnant women. Pregnant women should be given this information when they can fully consider their options (not in an emergency when they have little choice), and consent should be taken by an appropriately trained medic and clearly noted within their records.

The issue of taking proper consent during labour has recently been addressed in the UK case of Montgomery, that case conveyed that medics have an obligation to advise patients of all material risks, and that once a patient has been duly informed, they have the autonomy to make the ultimate choice about their own care. This case law echoes the informed consent ethos as defined in Geogheon v Harris in this jurisdiction.

Joining David on the panel discussion was Ogechi Nsoedo, Woman’s Physiotherapist. Mother and author of “Woman’s Health – practical perspective of pelvic floor injury”. She outlined that while any form of alteration can be considered a trauma, it is the extent of the alteration that is important. For many women it is not so much the trauma as the mechanism of healing and recovery that causes the greatest impact. She believes it is important to listen to women, to ensure they are referred to specialist physiotherapists and to maintain the link to health services and supports well after delivery.

Barrister Doireann O’Mahoney indicated that there was a perception mothers were under pressure to have a natural delivery and that many doctors are not receiving adequate training to manage complicated vaginal deliveries. She believes poor ante-natal discussions on delivery options, and little requirement for consent to forceps delivery are leading to many women experiencing 3rd and 4th degree perineal tears due to vaginal deliveries; injuries that would have been avoided if the baby had been delivered by Caesarian section.

For Avril McElwain, an Occupational Therapist with the HSE, it is important in the first instance for women to attend their own GP and Public Health nurse, to establish what is their ‘normal’ as it can differ from woman to woman. In the case of women experiencing bladder or anal incontinence, it is important to identify dietary triggers. It is also important to avail of all the supports that are available from health services, as well as counselling services for both partners, to provide the emotional support needed.

David stresses we need to move away from the paternalistic approach to obstetrics in Ireland, to inform and then listen to women more. With a two year limit on when a mother can take a case, many women miss this deadline as they are caught up with the responsibilities of new motherhood, while coping with the often life altering impact of the injuries they received during childbirth.

You can listen back to the panel discussion here.

If you, or someone you know, has been impacted by a birth injury and you would like further information please contact our Clinical Negligence team.