We all know your pelvic floor can weaken after giving birth. But lesser known is the fact the anal sphincter – the group of muscles which help to hold poo in – can also become damaged, with life-changing consequences.
Emily, who preferred not to share her surname, suffered a third-degree tear after giving birth vaginally to her second child in 2019. A third- or fourth-degree tear is where a tear in the perineum – the area between the vaginal opening and anus – extends into the anus.
“I didn’t really know what was going on,” Emily recalls. “I was given loads of antibiotics and constantly at the doctor’s for infections. I was told I was healing well.”
But Emily knew something wasn’t right. She would get a sudden urge to go for a poo, but wouldn’t be able to make it to the bathroom in time.
Discussing the impact, she says: “I was scared to go out as I constantly wanted to be near the toilet. I was also aware that I was leaking and I was worried that everyone would know, as I would be smelly.”
Emily, who is 42 and a mum-of-two, says she was eventually told by one consultant the issue would be something she’d need to learn to live with. They signposted her to MASIC, a charity which supports women who suffer serious injuries during childbirth.
Unhappy with the prognosis, and desperate to do something about it, she sought an appointment with a private consultant, who referred her for physio. She was given exercises to strengthen her sphincter muscle, as well as electrical treatment.
“I have lost a piece of my sphincter muscle and this can’t be replaced so it is just through exercise that I can strengthen [the muscle] to try and stop leakages and have more control,” she says.
“The consultant and physio both think, in the long term, that I will need surgery.”
In the UK, about three in 100 women having a vaginal birth will experience an injury to the anal sphincter muscle. It’s more common among those giving birth for the first time, occurring in six in 100 women.
The impact of anal sphincter injury can be devastating, affecting everything from long-term health and relationships to lifestyle and employment.
Sometimes the issue can be temporary and may resolve itself with pelvic floor exercises, other times it can be more permanent, requiring a more invasive form of treatment – but even then there are no guarantees it will be fixed.
Emily says she was concerned about going back to work as a teacher: “I was worried about the urgency and not getting to the bathroom – I can’t just run out of class.
“Stress is also a trigger and this concerned me. It has definitely impacted mine and my husband’s relationship. I feel more confident now, but for ages I wouldn’t go anywhere unless I knew where the toilets were.”
With there being such a stigma around our bowel habits, it’s unsurprising then that bowel incontinence can often leave new mothers feeling alone and ashamed.
“Almost all women with bowel incontinence symptoms following childbirth find it very difficult to talk about their condition to family, friends and partners,” says a spokesperson for support charity MASIC.
“It is very hard going to the doctor and asking for advice when bowel incontinence is an unspoken taboo.
“Feeling unclean is frequently expressed. This can have a profound psychological impact, diminishing a woman’s dignity and sense of self.”
There is a general lack of public awareness of the condition, they add, because health professionals are “reluctant” to discuss the long-term effects of birth injury “due to fear of scaring pregnant women”.
Bowel incontinence can impact new mothers in many ways. They might find their social lives are heavily restricted as they’re concerned about going out in public, or to work, for fear of soiling themselves.
“Many women experience social isolation, which some expressed by becoming a prisoner in their own home and feeling alone,” says MASIC’s spokesperson.
It can also feel degrading. “There is often leakage of waste during exercise, fear of being incontinent during sexual intercourse, loss of confidence, and feelings of failure as a mother,” adds the spokesperson.
Mum-of-three Gabriela, 39, suffered a third-degree tear after giving birth to her first child, however it wasn’t discovered until six months later – by which point it was too late to repair.
She is certain that the use of forceps during delivery contributed to the damage. The biggest risk factor for this kind of injury is a first vaginal birth, says MASIC. However the next most important risk factor is the need for an instrumental delivery. The risk is higher for forceps delivery than the suction cap (Ventouse), says the charity’s spokesperson.
“When I had my first baby I recall complaining about faecal incontinence right away – even the day after the birth,” says Gabriela. But she claims she was repeatedly told she needed to do pelvic floor exercises.
“This wasn’t it at all,” says the stylist. “I had looked it up online and faecal incontinence was not considered ‘normal’ after a birth at all, however urinary incontinence was.”
Gabriela would have multiple accidents including soiling herself because she couldn’t hold it, or soiling herself as she headed to the toilet.
Recalling her worst episode, she says she was holding her baby in her arms as she walked upstairs to the toilet. “Faeces was just running down my leg from my shorts until I made it up to the bathroom,” she recalls.
“I remember it like it was yesterday. I started to cry and my body was shaking.”
She laid her baby down in the cot and cleaned herself up. But sadly it’s not uncommon for her to have daily accidents. “Other bad days are when I have diarrhoea,” she notes, “these days I try not to go out at all if possible.”
The impact on her life has been far-reaching. “One of the saddest impacts has been the relationship with my son,” she admits. “I can tell that my time with him as a baby was affected, as I resented him for what happened to me. I was angry and depressed.”
Her relationship with her husband was also impacted as “his life seemed just fine after us having a baby, but mine was never going to be the same ever again”. Sex, she adds, “was scary and painful – even embarrassing”.
Understandably, those impacted by such injuries may feel extremely anxious about having another baby because what happens if it makes the issue worse?
Gabriela was sure she would never have children again, but after undergoing therapy and also focusing on her faith, she decided she “wasn’t going to let fear win”. She has since had two more children – both of whom were born in a private hospital via C-section – which “massively made a difference”.
Both Emily and Gabriela will now likely have to contend with bowel issues for the rest of their lives. “The older I get the more issues I have with wind and, in general, I experience more accidents,” Gabriela says.
“So there is no easing over time here. In fact, I have been told that it will only get worse. When I go through menopause it will become worse and I may end up having to get a stoma or surgery.”
“One of the saddest impacts has been the relationship with my son. I can tell that my time with him as a baby was affected, as I resented him for what happened to me.”
- Gabriela
Women struggling to hold in flatulence or poo, or having accidents, after birth should speak to their GP and request a referral to a colorectal nurse practitioner who runs a functional disease clinic, or a perineal clinic, advises MASIC.
The Royal College of Obstetricians and Gynaecologists (RCOG), in collaboration with the Royal College of Midwives, is encouraging all maternity units to adopt something called the OASI Care Bundle, which aims to improve the health and care of women, and to reduce the risk of severe tears.
Dr Ranee Thakar, president of RCOG, tells HuffPost UK: “Severe perineal tears during birth can have a huge long-term impact on a woman’s quality of life, including bowel incontinence and pain during sex.
“It is vital that healthcare professionals and women can have meaningful discussions to enable women to make informed choices about their care.”
The OASI Care Bundle includes recommendations to discuss the risks with women during their pregnancy, and evidence-based interventions that can reduce the risk of a severe tear.
One such intervention is that the midwife or doctor could use their hands to support both the perineum and baby’s head during the birth, while communicating with the woman to encourage a slow and guided delivery.
The guidance also suggests that after all vaginal births, an examination of the vagina, anus and rectum should be offered to all women – even if the perineum appears intact “to ensure that any tears are identified immediately and that treatment options are discussed and implemented as necessary”.
When we asked NHS England whether the OASI Care Bundle is implemented by maternity units, a spokesperson said: “NHS England supports the care bundle and agrees that all women should be educated about the risk of pelvic health problems around birth and have timely access to support when they need it, in line with NICE guidance.”
The NHS is in the process of rolling out perinatal pelvic health services, which are now in place across two thirds of the country, they said. The aim of these services is to “improve the prevention, referral and timely treatment of pelvic health problems antenatally and for at least a year after birth”.
The rollout to remaining parts of England will begin from April 2023.
Gabriela now wants to see better education both for healthcare professionals and parents having children regarding their options for birth so they “know the real facts”, as well as an investigation and research conducted into whether forceps should continue to be used on women for delivering babies.
“Change needs to happen,” she says, “and now is the time.”
Emily reflects that she would have benefitted from more postpartum support and check-ins, and a more thorough investigation of what had gone wrong.
“Without my own research and an element of luck, I wouldn’t be where I am,” she says.
Her future is looking a little brighter – having seen the physio while continuing with the exercises, she says she hasn’t had an accident in three years now. That said, she still experiences leakages from time to time.
“The physio support has been the most help,” she says. “Without accessing this, and as quickly as I did, I really don’t think I would have made the progress that I have.”