Pelvic floor complications after vaginal birth : short- and long-term consequenses for primiparous women in Sweden

Women giving birth to their first baby often sustain some form of perineal injury. These injuries can cause short- and long-term pelvic floor dysfunction symptoms and may affect their health. This thesis focuses on a sample of 597 primiparous women who participated in the MIMA (Midwives’ Management during the Second Stage of Labour) project. MIMA demonstrated a reduction of second-degree tears related to supporting slow birth of the baby’s head, in combination with spontaneous pushing in a flexible sacrum position.

AIM: The overall aim of this thesis was to investigate and evaluate perineal injuries, postpartum pelvic floor complications and consequences affecting women after the birth of their first child, up to 1.5 year postpartum. Specific research questions were applied to investigate the prevalence of and women’s experiences of haemorrhoid symptoms, perineal pain, postpartum care, urinary incontinence (UI), anal incontinence (AI) and bowel-emptying difficulties.

METHODS: Study I, a mixed method study with an experimental, explanatory, sequential design, investigated the prevalence and women’s experiences of haemorrhoid symptoms (n= 496). An initial quantitative phase was followed by qualitative content analysis. Studies II-IV were cohort studies. In Study II, in which 461 women participated, we investigated the prevalence of perineal pain and postpartum care uptake. Study III and Study IV included 410 women and investigated the prevalence of UI, AI and bowel-emptying difficulties related to obstetric variables. We applied bivariate analysis and logistic regression, adjusting for risk factors (Study I). Descriptive statistics were used to present data, and the Chi-Square test was used to compare perineal pain and severity of perineal injury during the first year postpartum (Study II). Data in Study III and IV were analysed with the Chi-Square test, and Study III also included the Independent t-test.

RESULTS: Study I: Women managed with the MIMA model of care reported fewer haemorrhoid symptoms three weeks postpartum, compared to women in the standard care group. The MIMA model remained protective after adjusting for potential risk factors (adj. OR 0.6; 95% CI 0.4-0.9). Half of the women had remaining symptoms 1.5 year postpartum and these women experienced that they had been neglected in the healthcare system. Study II: The severity of perineal injury was related to the occurrence of perineal pain during the first year postpartum. A majority (75.0%) of the women with a severe injury, more than half (61.8%) with type-II moderate injury and 44.0% with type-I moderate injury reported perineal pain three months postpartum (p <0.002). At six months postpartum, the corresponding respective figures were 60.0%, nearly 40.0% and one-fifth (p <0.001). One in four women who attended the postpartum visit did not undergo vaginal examination and was not given any advice about pelvic floor exercises. Study III: About 40% of the women had UI, of which stress urinary incontinence was the most common type, 9–12 months after birth. Known risk factors, i.e. long duration of the second stage and the baby’s head circumference and birth weight, were not associated with the prevalence of UI. Study IV: Women sustaining minor or second-degree tears complained of bowel-emptying difficulties or AI 9-12 months postpartum at a rate comparable to those who had tears involving the anal sphincter complex. Studies III and IV: The women reported that AI and UI had an impact on their daily activities, as well as significantly impairing psychological wellbeing.

CONCLUSIONS: Slow birth of the baby’s head in combination with spontaneous pushing may reduce haemorrhoid symptoms three weeks after delivery in primiparous women. Nearly half of the women had persisting haemorrhoid symptoms 1.5 year postpartum, and they experienced that they had been neglected in the healthcare system. Perineal pain was associated with the severity of perineal injury. Women with moderate injuries had persisting perineal pain six and twelve months after delivery. One in four women suffered from UI 9–12 months postpartum. Furthermore, women experienced that UI and AI impacted their daily activities and significantly affected their psychological wellbeing. Women sustaining minor or second-degree tears had bowel-emptying difficulties and AI 9-12 months postpartum at a rate comparable to those who had tears involving the anal sphincter complex.

List of scientific papers

I. Susanne Åhlund, Ingela Rådestad, Sofia Zwedberg, Malin Edqvist, Helena Lindgren. Haemorrhoids – A neglected problem faced by women after birth. Sexual & Reproductive Healthcare. 2018,18,30-36.
https://doi.org/10.1016/j.srhc.2018.08.002

II. Susanne Åhlund, Ingela Rådestad, Sofia Zwedberg, Helena Lindgren. Perineal pain the first year after childbirth and uptake of post-partum check-up, a Swedish cohort study. Midwifery. 2019 Aug 5;78:85-90.
https://doi.org/10.1016/j.midw.2019.08.004

III. Susanne Åhlund, Emilia Rothstein, Ingela Rådestad, Sofia Zwedberg, Helena Lindgren. Urinary incontinence after uncomplicated spontaneous vaginal birth in primiparous women during the first year after birth. Int Urogynecol J. 2019 May 28.
https://doi.org/10.1007/s00192-019-03975-0

IV. Emilia Rotstein, Susanne Åhlund, Helena Lindgren, Angelica Hirschberg, Ingela Rådestad, Gunilla Tegerstedt. Posterior compartment symptoms in primiparous women one year after non-instrumental vaginal deliveries - a Swedish cohort study. [Manuscript]