The theme for Birth Trauma Awareness Week 2022 (18-23 July) is Physical Birth Injuries: diagnosis and treatment. In the light of this theme, we invited our expert friends from MASIC - the only multi-disciplinary UK charity to support those who have suffered Obstetric Anal Sphincter Injuries (OASI) - to answer your OASI related questions.

TRIGGER WARNING: Please read this story with care. If you’re finding the content challenging, please give yourself permission to step away. If you need support click here, if you need urgent help click here.

At the start of BTAW 2022 we posted a question box on our Instagram feed where our followers could share any questions they had on OASI. In answer to these questions, we have five experts from MASIC sharing their knowledge. They have included many resources for further reading too. Please contact us at hello@makebirthbetter.org if you have any other questions on this topic.

“Please can we talk about the arbitrary limitations (such as no (heavy) lifting, no high impact exercise or being encouraged to lose weight) imposed on women with a prolapse diagnosis in the name of so called evidence?”

Answered by Sam Vincent, MASIC Council Member and Perinatal Pelvic Health Specialist Physiotherapist.

“Thank you so much for bringing this to the discussion. I completely agree with you that a prolapse diagnosis can be devastating and have seen this first hand in my clinic time and time again. I am mostly delivering this news to mothers, who have new-born and young children so lifting is inevitable. They sometimes also want to get back to feeling themselves physically and mentally with exercise, running is a common one for convenience of time and cost. So I hear you and your frustration, and have seen the anxiety these new 'rules' can place on a woman.

I have included the information from NICE's Urinary Incontinence and prolapse management guidelines in 2019. Under lifestyle modification it states:

‘There was no evidence available on lifestyle modification to manage pelvic organ prolapse, so the committee used their knowledge and clinical experience to make this recommendation. They thought that advice on aspects of lifestyle that directly affect the pelvic organs is most useful for women with pelvic organ prolapse. The committee agreed that obesity, heavy lifting and constipation all exacerbate the symptoms of pelvic organ prolapse by increasing intra-abdominal pressure.’

I am so sorry that such direct information was provided to you to not lift or carry out high impact exercise, as I personally (along with many other pelvic health physiotherapists I work alongside) would not prescribe this, as this is not in the NICE guidelines as you can see above, more rather NICE acknowledges, and we as clinicians should be aware that activities which raise intra-abdominal pressure can be a risk factor for prolapse worsening. However, we should aim to treat patients holistically i.e. as a whole person, and not just the prolapse.

I would hope that clinicians working with women with prolapse treat everyone individually. Life is about balance, and I believe with the right support there should not be such restrictions. As we age and then finally progress into the menopause, we NEED both cardiovascular exercise and also weight training to keep up our bone density and muscle mass. So I agree, we cannot just eliminate lifting and forms of high impact exercise, otherwise we will see other future issues. In summary, NICE has some guidelines that are there for just that, guidance to the clinician. Never lift, never do high impact and you must lose weight are harsh, I agree, and the clinician supporting you should always take you and your life into consideration to help you achieve your goals and live your life as prolapse worry free as possible.”

“Can anything be done if you’re left with total perineal deficiency?”

Answered by Bob Freeman, MASIC Executive Trustee and Consultant Professor in Urogynaecology at Plymouth University Hospitals.

“Reconstructive surgery is on offer for a patient presenting with perineal deficiency. A full consultation with your consultant would be needed to assess the degree of deficiency and options available. For further guides to surgery and treatments available after birth injury see the IUGA resource leaflets here.”

“Are there any peer support groups for OASI families?”

Answered by Jen Hall, MASIC Advocate and Website & Social Media Coordinator.

At MASIC we offer peer support via our private Facebook support group here – connecting women and families from across the UK who have experienced OASI injury. This is a private group so you will be asked a couple of admission questions before joining. We also have a MASIC WhatsApp support group, please email socialmedia@masic.org.uk if you are interested in joining us. Also, we offer a face to face OASI support group based in Cardiff, please follow Rhi at @amumfromthediff for more details, or if you are interested in attending. We are launching a North-West Support group in Manchester in October this year. Please email admin@masic.org.uk if you are interested in attending or follow @tears_from_tearing for updates.

“How might you prepare for another birth after OASI?”

Risk assessment plays a vital role when it comes to supporting a woman deciding on mode of delivery after a previous OASI Injury. This free webinar link here should prove useful for anybody preparing for another birth after OASI. It includes stories from our MASIC advocates who have previously suffered OASI and gone on to have another birth.

*Trigger warning: Please note MASIC webinars contain medical advice and sometimes graphic images which may not be suitable for everyone. *

The following advice also from Bob Freeman, MASIC Executive Trustee and Consultant Professor in Urogynaecology.

There is a 7% risk of recurrence if undergoing vaginal birth after previous OASI

Anorectal physiology tests would help to know if the sphincters are intact and strong enough (suggest requesting these). If not available at your hospital they will be elsewhere.
If the sphincters are OK then a vaginal delivery using the OASI Care Bundle including perineal support and episiotomy would help prevent another tear.
If an instrumental delivery is required there is less risk of a tear with ventouse compared with forceps. However if delivery is deemed urgent e.g baby is distressed, then be guided by the obstetrician; he/she should use the instrument that can deliver the baby quickly and safely (forceps are usually quicker).
If the test shows the sphincters not to be intact or the strength/pressures are weak then planned caesarean is a good option.

See RCOG patient information on OASI here.

“What treatment is on offer?”

Answered by Professor Mike Keighley, MASIC President and Retired Professor of Colorectal Surgery at Birmingham University Hospitals.

“Physiotherapy, bowel management: washout, toilet training, perineal reconstruction/sphincter repair and Sympathetic Nervous System (SNS) nerve stimulators all have a part to play in treating women after an OASI injury. Please head over to the Getting Help section of the MASIC website here where you will see what kind of help is available on the NHS and privately.

You can also see our MASIC downloadable guides to the different types of surgery and treatments on offer and how to prepare for them here and the following nurse-led coping advice here.

Please also watch our free webinar here on Managing the Consequences of OASI which includes advice from a pelvic health physio, MASIC advocates, colorectal nurses and specialists in bowel irrigation techniques.”

*Trigger warning: Please note our webinars contain medical advice and sometimes graphic images which may not be suitable for everyone. *

“How can we rebuild sexual connection after OASI?”

Under ‘PowerPoint downloads’ on the MASIC website here you will find the slideshow ‘Sex after Perineal Trauma’ which offers advice from Kate Walsh @katewalshphysio and Emma Matthews.

MASIC would also advise seeking specialist psychosexual counselling if needed, and a directory of specialists can be found here.

BTAW 2022: Q&A on OASI with experts from MASIC