The truth about childbirth injuries


Cosmopolitan Magazine recently published an amazing piece on childbirth injuries, Millions of Women Are Injured During Childbirth. Why aren’t doctors diagnosing them?

Why do childbirth injuries occur?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Childbirth injuries are common, lead to life long disability and distress and are a subject of deep embarrassment for many women.[/pullquote]

The single greatest cause is a mismatch between the size of the baby and the size of the passage it must negotiate during birth. There are two different points at which the mismatch can cause problems. The first is during passage of the head through the maternal bony pelvis. The second point is when the head exists the vaginal opening.

Most people imagine that the pelvis is like a hoop that the baby’s head must pass through, and indeed doctors often talk about it that way. However, the reality is far more complicated. The pelvis is a bony passage with an inlet and an outlet having different dimensions and a multiple bony protuberances jutting out at various places and at multiple angles. The baby’s head does not pass through like a ball going through a hoop. The baby’s head must negotiate the bony tube that is the pelvis, twisting this way and that to make it through.


You can see what I mean in the illustration above (from Shoulder Dystocia There are bony protuberances that jut into the pelvis from either side (the ischial spines) and the bottom of the sacrum and the coccyx, located in the back of the pelvis, jut forward. How does the baby negotiate these obstacles? During labor, the dimension of the baby’s head occupies the largest dimension of the mother’s pelvis. But because of the multiple obstacles, the largest part of the mother’s pelvis is different from top to middle to bottom. Therefore, the baby is forced to twist and turn its head in order to fit.

What happens when the baby’s head doesn’t fit? The bones of the mother’s pelvis may break or split to accommodate the baby. That’s why a woman might end up with a fractured coccyx or a separated public symphysis, both extremely painful.

If the bones don’t break or split (and sometimes even if they do), the tissues of the vagina can be squeezed so hard between the baby’s head and the mother’s pelvis that the blood flow to the area is actually stopped. If that goes on for more than a few minutes, the tissue of the mother’s vagina will begin to die resulting in a hole (fistula) in the vagina. If the hole is toward the front of the vagina it will open into the bladder and if it is toward the back it will open into the rectum; there can be holes in the front and the back simultaneously.

In either case, waste products leak into the vagina and dribble out of it rendering the woman incontinent and reeking of urine and/or stool for the rest of her life. Fortunately, easy access to C-sections means that it is rare for women to push for multiple hours with no progress and obstetric fistula is therefore uncommon in industrialized countries today.

What happens when the baby’s head is too big to fit through the vaginal opening? The vagina tears to accommodate it. If the vaginal tear is small, it will heal by itself. If the vaginal tear extends into surrounding structures it will not heal unless it is sutured properly.

Perineal tears are classified by severity from first to fourth degree. First degree tears are small do not need to be stitched. Second degree tears extend into the tissue immediately surrounding the vagina; they ought to be stitched but the results are not catastrophic if they are not stitched.

Third and fourth degree tears are more serious. The illustration of the fourth degree tear below make it easy to see why they MUST be stitched or the woman will be left with bowel incontinence. Third and fourth degree tears can only be diagnosed by someone with considerable obstetric experience and they will NOT heal by themselves. They must be repaired by someone with extensive experience in repairing them.


Why aren’t childbirth injuries diagnosed? I offered my take in the piece:

We have a new cultural view of childbirth that tremendously minimizes how physically and emotionally difficult it is.

Indeed, until relatively recently, childbirth was recognized not merely as deadly, but also as disfiguring and disabling. A historian Judith Walzer Leavitt wrote in Under the Shadow of Maternity: American Women’s Responses to Death and Debility Fears in Nineteenth-Century Childbirth:

In the past, the shadow of maternity extended beyond the possibility and fear of death. Women knew that if procreation did not kill them or their babies, it could maim them for life. Postpartum gynecological problems – some great enough to force women to bed for the rest of their lives, others causing milder disabilities – hounded the women who did not succumb to their labor and delivery. For some women, the fears of future debility were more disturbing than fears of death. Vesicovaginal and rectovaginal fistulas .., which brought incontinence and constant irritation to sufferers; unsutured perineal tears of lesser degree, which may have caused significant daily discomforts; major infections; and general weakness and failure to return to prepregnant physical vigor threatened young women in the prime of life.

What changed between then and now? Quite a few things:

The widespread medicalization of childbirth dramatically reduced the death rates for both babies and women. In the past 100 years, modern obstetrics dropped the neonatal mortality rate 90% and the maternal mortality rate nearly 99%. Childbirth began to be seen as safe.

The medicalization of childbirth dramatically reduced the risk of the most debilitating childbirth injuries. The most devastating injuries, obstetric fistulas, have been rendered exceedingly rare by the easy availability of C-sections, and the more common injuries are easily prevented by the simple expedient of suturing vaginal tears.

Midwives and the natural childbirth industry romanticized childbirth in order to claw back market share. Midwives and other natural childbirth advocates resented what they derided as the “technocratic” model of birth, which they contrasted with the midwifery model which places a premium on avoiding the childbirth interventions that they coincidentally cannot provide.

We’ve ended up with a situation where physicians ignore postpartum pain, incontinence and sexual dysfunction because they are pre-occupied with preventing deaths, and midwives and natural childbirth advocates pretend childbirth injuries don’t exist because those injuries belie their reflexive worship of birth without interventions.

The truth about childbirth injuries is that they are common, can be prevented to a certain extent with the liberal use of obstetric interventions, can lead to life long disability and distress and are a subject of deep embarrassment for many women.