Birth trauma

Birth Trauma – what does this mean to me?

In Australia, up to one in three women experience a ‘traumatic’ birth, with about 5% of these women developing a post traumatic stress disorder (PTSD).

It's a scary figure when you consider just how often society tells us our pregnancy will leave us ‘glowing’ and how much emphasis is placed on birthing ‘vaginally’, as opposed to birthing 'safely' – which for me as an obstetrician involves both the physical & psychological safety of a mother.

Both my own births were vaginal. My first was fast and furious and done in under four hours. I had a little baby, a tiny tear, and was a great milk bar. I loved both the birth and the postnatal period.

My second birth however was a completely different story, and it left me with both permanent physical damage and birth trauma. If I could have a ‘re-do’ (don't you wish for this at times!) I would have chosen an elective caesarean section.

I love birthing. It’s one of the most intimate and one of the most amazing parts of life. But it is also one of the most terrifying.

So what is birth trauma?

Although most birth trauma is more commonly related to the birth itself, stressful pregnancies complicated by issues such as a short cervix, high-risk twins, placenta praevia, or hyperemesis gravidarium, can all be 'traumatising'.

Birth trauma is most commonly associated with birthing where physical trauma occurs. This may include birthing requiring a forceps delivery, massive bleeding after birthing, nasty vaginal, perineal and rectal tears, unexpected resuscitation for mum or baby, life-saving hysterectomies, or unexpected trips to theatre. In these situations a mother can be left with a number of physical challenges, some short-term, and some for a lifetime.

Even when all goes well physically, the pain and uncertainty of the ‘marathon of birth’, is enough itself to be traumatic for many women. Add in failed hopes, unmet expectations and disappointment, and the risk of birth trauma, both physical and psychological, is ever present.

What should you do if you experience birth trauma?

If you have experienced birth trauma, the most important step to take is to tell someone, whether it be your partner, your midwife or obstetrician, or a close friend.

Ongoing physical trauma or disability is likely correctable, but without acknowledging it your healthcare team cannot give you the best chance of recovery. As healthcare providers we also take responsibility, asking each woman about bowel, bladder, and pelvic floor function and sensation at each postnatal appointment.

Psychological trauma needs acknowledgement and the opportunity for support, both formally and informally. With 1 in 7 mothers and Australia experiencing postnatal depression, and up to 1 in 3 describing a traumatic birth, healthcare providers should be debriefing every woman’s birth, assessing each new mum for depression and birth trauma.

Birthing is one of the most amazing experiences – but for many, also one of the most terrifying life experiences. Your whole world changes in a day.

Thankfully most births are challenging, exhausting, exhilarating and joyous, but not always. As a community we need to better acknowledge birth trauma, and so better support our women and their families when it comes to birthing and parenting.

Resources:

• Birth Trauma Association (UK)

• Perinatal Anxiety & Depression Australia

Having a hysterectomy

I’m having a hysterectomy. What do I need to know about this operation?

A hysterectomy is the surgical removal of your uterus. It usually also includes the removal of your cervix and may include removal of fallopian tubes and ovaries. In Australia about 1 in every 30 women will need or seek a hysterectomy.

Women choose a hysterectomy for many reasons, including heavy bleeding, pelvic pain and uterine prolapse. Other hysterectomies are done for life-saving reasons such as for cancer treatment or life-threatening uterine bleeding.

There are three different ways gynaecologists perform hysterectomies

1. Total abdominal hysterectomy

The first is an abdominal hysterectomy (AH) that involves an open abdominal incision, usually horizontal just along the bikini like. This is often performed for very large uteruses that have fibroids, or where women have severe abdominal adhesions from previous surgery, severe endometriosis, or infections. Recovery in hospital usually takes 4-7 days and usually women require 6-8 weeks before resuming normal activity. Although less commonly needed today because of the availability of 'keyhole' surgery, sometimes this 'open' surgery is still required. At TasOGS both Dr Connan and Dr Hingston can perform this type of hysterectomy.

2. Total laparoscopic hysterectomy

The second surgical method is the total laparoscopic hysterectomy (TLH) also sometimes called a ‘key-hole’ hysterectomy. This technique is used for hysterectomies where the tubes and/or ovaries are also being removed, where excision of endometriosis is also occurring, and often for women who have not had vaginal births and so a vaginal hysterectomy is not possible. Recovery is hospital is usually 1-3 days and women can often resume normal activity 2-4 weeks after surgery. This type of hysterectomy is best performed by gynaecologists who have additional training in advanced laparoscopy ('key-hole' surgery).

After 5 years of general training Dr Connan spent 18 months at the Royal Women’s Hospital (Melbourne) specialising in endometriosis 'key hole' surgery and laparoscopic hysterectomies. She then worked as a specialist in the same gynaecology team from 2010 to 2013. For the past 7 years laparoscopic hysterectomies have been Dr Connan’s primary method of hysterectomy in those for whom the technique is suitable.

3. Vaginal hysterectomy

The third hysterectomy technique is the vaginal hysterectomy (VH) that requires only an incision in the vagina. This is usually the technique of choice for women with a normal-sized uterus having had previous vaginal births or pelvic floor prolapse. Recovery is hospital is usually 2-3 days and women usually require 6 weeks before resuming normal activity. At TasOGS Dr Hingston performs this type of hysterectomy.

Which surgical technique should I have?

This is best discussed with your gynaecologist. There are differences with surgical risks and differences with recovery among the different methods of hysterectomy, making the choice very dependent on features and characteristics of both patient and uterus. Not all gynaecologists can do all types of hysterectomy.

Are there advantages to a ‘key-hole’ laparoscopic hysterectomy (TLH)?

When compared with a traditional 'open' hysterectomy, a laparoscopic hysterectomy often reduces recovery time, hospital stay, and postoperative pain, but may be associated with a slightly higher risk of complications (in particular urinary tract injuries), particularly when performed by less experienced gynaecologists.

What questions should I ask my gynaecologist?

It is important to understand the reason why you may need a hysterectomy, and if one technique is recommended over another, the reasons why one type of surgery may be more suitable for you.

Every patient and every uterus is different, and what may be suitable for one person may not be the best choice for another.

Other questions that may be helpful to ask include:

• How many hysterectomies have you done? And of this type?
• What is your complication rate?
• How do you manage such complications?
• How long will I stay in hospital?
• When can I drive after surgery?
• When can I have sex after surgery?
• When can I return to all normal activities?
• Do I still need PAP smears?
• Does this influence my menopause?

Although recovery after a laparoscopic or vaginal hysterectomy can be rapid, hysterectomies are still a major operation. Make sure you have all your questions and concerns answered before your surgery.

At TasOGS we strive to make sure you are well informed before any surgical procedure you may require. Please speak to your gynaecologist if you have any further questions or concerns.

Diabetes and Pregnancy

Gestational Diabetes. What does this mean for me?

This week is National Diabetes Week in Australia.

Everyone knows someone who has or will have diabetes. In Tasmania there are over 25,000 people who live with diabetes.

Type 1 diabetes mellitus (T1DM) is more common in childhood and early adulthood. Type 1 diabetes can be inherited, but can also arise for the first time with no family history. A healthy lifestyle and diet, insulin injections or insulin pump are the main treatments.

Type 2 diabetes mellitus (T2DM) is more common as we get older. This is now the commonest type of diabetes. Family history (which none of us can escape) and obesity remain the two leading risk factors. A healthy lifestyle and diet, oral tablets and less commonly insulin, are the mainstays of treatment.

Gestational Diabetes Mellitus (GDM) is diabetes of pregnancy. This is usually diagnosed at 24-28 weeks of pregnancy with an oral glucose tolerance test (OGTT), and is seen in 10-15% of pregnancies. Not all women who develop GDM have risk factors (such as obesity, family history, previous GDM or age over 40 years), although these make the condition more likely. Once again, a healthy lifestyle and diet, oral tablets and sometimes insulin, are the main treatments.

Women with diabetes in pregnancy (T1DM, T2DM and GDM) all require a team approach to managing both their diabetes and their pregnancy. The team usually includes the woman and her family supports, her obstetrician, endocrinologist, diabetes educator, dietician and psychologist. Others may be required if the pregnancy or diabetes develops complications.

At TasOGS, as obstetricians who frequently manage women with diabetes in pregnancy we are aware of the different ways in which the different types of diabetes can affect mother, pregnancy and baby.

Extra attention is required to monitor pregnancies involving diabetes as they can have higher rates of complications. These include greater risk of miscarriage, blood pressure problems, risk of both extremely small and extremely large babies, higher rates of early birth, higher caesarean section need, risks of antenatal and postnatal depression, and higher rates of admission of newborn babies to the neonatal nursery.

Pregnancy can also accelerate some of the general complications of diabetes. Knowing this we encourage all women with diabetes to first discuss pregnancy planning with their GP, endocrinologist, or high-risk obstetrician before getting pregnant.

Diabetes is common. In pregnancy diabetes challenges both a women’s physical and psychological wellbeing, as well the wellbeing of her baby and birth experience. Understanding and support is one way to improve this experience for all.

We encourage your support of Diabetes Australia to enable further research in diabetes prevention, treatment and cure.

Endometriosis – painful or painless?

Period pain – what’s all the fuss about? I must first confess that I have never really had major issues with my periods. When I was young having them was a nuisance on sports day, but other than the social inconvenience, they never amounted to much. After I completed my family I was keen to avoid them, and a Mirena IUD has been my solution – though not necessarily the right solution for everyone.

For many women however, including some of my closest friends, periods have defined, redefined and even destroyed their lives at times.

As a obstetrics & gynaecology trainee my interest in period pain arose from my love of laparoscopic surgery. From this interest I spent 18 months training in advanced laparoscopic surgery at the Royal Women’s Hospital in the Pelvic Pain/Endometriosis unit. After my training I took a specialist role and continued to work in the Unit as a gynaecologist and surgeon. Women from all over Victoria and beyond came with pelvic pain looking to us for answers and solutions for their pain.

Many things can cause pelvic pain

Endometriosis is one of the diseases that can cause pelvic pain. Defined as 'ectopic endometrial tissue' – meaning tissue that's normal found only in the lining of the uterus, shedding once a month to give you your period, is instead also found outside the uterus elsewhere in the pelvis. Endometriosis can be associated with debilitating and life-destroying pain.

Painful periods, pain when you have sex, pain when you open your bowels, pain mid-cycle or all-cycle, spotting before your period, bloating and infertility are just some of the common symptoms that you might experience with endometriosis.

Endometriosis diagnosis & treatment

Diagnosis and treatment of endometriosis is most effectively done with surgery, although we generally start first with simpler interventions.

Ultrasound has improved dramatically over the last few decades, and can now identify endometriosis cysts (endometriomas), and in specialised ultrasound facilities (such as Women’s Imaging in Hobart for Tassie Women) can also find deeply invasive endometriosis.

However because only 5% of  those with with endometriosis will have either endometriomas or deeply invasive endometriosis, many women even with strongly-suggestive symptoms can still have a normal ultrasound. For these women laparoscopic surgery may be required to find answers.

Adding to the myriad of symptoms that women with endometriosis often experience, unfortunately even surgery to remove areas of endometriosis doesn’t always result in complete relief from symptoms or improvement in fertility.

While surgery to excise, rather than simply cauterise, areas of endometriosis is often very effective, we also know that for many women endometriosis will recur in the future, requiring more surgery and the potential risks that that brings.

Endometriosis – an often ignored women's health issue

For many women I’ve met and cared for with endometriosis, their stories of being told ‘you're a woman, it's normal to have painful periods’, ‘just take a panadol’, or ‘it's all in your head’ are sadly all too frequent.

Women with endometriosis are often challenged daily with pain. Their pain is real and often profound. It often impacts every part of their lives. What they need first is acknowledgement and understanding of their condition.

At TasOGS we believe endometriosis is all too often one of the unheard women’s health issues. Considering it effects up to 1 in 10 women, it’s likely that you know someone who is affected but who may have never spoken about it.

If you have symptoms that you think might be related to endometriosis, make sure you talk to your GP. There are many treatments, including both medications and surgery, than can be useful in managing the often debilitating symptoms of endometriosis.

There are also many great websites with more information about endometriosis, including Endometriosis Australia and the Pelvic Pain Foundation of Australia.