Reaping pain from what others have sewn

For too long new mothers have risked mutilation from bad suturing. Monica Brimacombe reports

Two years after giving birth to her son, Anna Walton still feels mutilated and her sex life is ruined. The labour was long and difficult, requiring forceps for delivery of her healthy son. A physiotherapist, she had prepared well for Steven's birth but says nobody prepared her for what it did to her body.

Like 70 per cent of women, she needed repair and stitching of the vagina and perineum after the birth. Despite the high incidence of such repairs, nobody monitors either the repair procedure or subsequent healing. Training is limited to practice sessions on a sponge before midwives are let loose on the real thing.

Little wonder then that 30,000 women a year suffer from poor post-natal stitching. Researchers have found one-fifth of all new mothers still have major problems, often requiring surgery, three months after delivery.

"At first I thought, this is childbirth, this is normal, but I couldn't walk or sit for six weeks. When I next looked at myself I was bruised, there was an extra hole down there - I was mutilated. The stitching was terrible," says Mrs Walton. "It's not just that sex doesn't feel right - my vagina is so big that it just doesn't work anymore."

Although the perineum is less than 4cm long, its position, between the vagina and rectum, along with its muscular structures, mean its rupture can cause profound problems. Stress can stop breast milk, and the resumption of sexual relations can be delayed. It is not unusual for sex to be uncomfortable - or impossible - for 18 months, with many women reporting bleeding and pain two years on.

Lucy Lewis, a research midwife at the Whittington Hospital in north London, set up a long-term study of the problem after having her first child. "It took up to 18 months for some women to be referred for help." Most alarming was the lack of follow-up of perennial healing after childbirth.

"I've been suturing for five years and I don't know if I've caused pain or a breakdown in sexual relations, or whether it's been fine," says Ms Lewis. It's not even down to caring, she says. "You can be painstaking, thinking your doing a wonderful, careful job, but at the end of the day if you haven't the knowledge to do it in the correct manner, if you don't know anatomy and physiology because you learnt it 15 years ago, how do you know? Nobody tells you if you've done a good job or made a real mess."

Indeed, post-natal repair is so ad hoc that some women patients now refuse any stitching at all. There seems to be no set procedure, no clinical evaluation of what course might be best for the patient. Different midwives and doctors use different procedures, materials and pain relief, not just in different hospitals but in the same hospital on the same ward and working under the same consultant.

The Whittington study, Are you sitting comfortably, aims to end all that. It asks volunteer new mums to write diaries of their post-natal experiences at 10 days, six weeks, eight months, one year and 18 months after the birth. These are returned to their midwives, who can choose to show them to Ms Lewis.

The most striking fact has been the change in midwifery practice as a result of the on-going research. Fewer midwives are suturing grazes routinely and many have asked for further training.

"The research has triggered midwives to look at their practice. It enables change and encourages it," says Ms Lewis

It is not just midwives who will benefit. Junior obstetricians rarely get feedback on their stitching. Until recently most repairs were done by students. "Obstetric registrars are often in the posting for one year. By the time their patient comes back with problems they are long gone," says Ms Lewis.

Ironically, the doctor who so mutilated Anna was instructing a medical student in the art of suturing while doing so. "He said, `the mother doesn't bother me, only the baby'," says Anna.

Dr Gaye Henson is a consultant obstetrician at the Whittington. She says the study has provoked a keen interest in retraining and may, at last, align practice with research. For instance, although one type of stitching is regarded as least problematic, few midwives know how to do it. In some cases hospitals are using outdated materials for repairs simply because they are not aware of the latest research.

Now, the Whittington is preparing to change its practice. Rather than retraining all labour ward staff, the hospital plans to nominate and retrain key midwives and doctors as perennial support workers. They will relearn anatomy and physiology alongside current research and practice and pass this on to their unit. A psychosexual counsellor has been assigned to the research project and herbal remedies - already found to have particular post-natal healing qualities - are being formally considered.