Laura’s Story

My name is Laura, and I am 32 years old, residing in Upstate New York. Professionally, I am a nurse practitioner, and I am also a wife and mother to a beautiful baby boy. As I sit down to share my story, my heart feels heavy yet hopeful. I hope that by opening up about my experience, I can find solace in connecting with others who have also faced the challenges of a severe obstetrical laceration and traumatic birth. A day that was supposed to be filled with anticipation and joy turned into a whirlwind of fear and uncertainty. The labor that was meant to bring us closer to our new baby led us down a path of unexpected outcomes and complications.

Starting from the very beginning, my pregnancy was fairly uncomplicated, except for finding out that I was COVID-positive and pregnant on the same day, followed by a diagnosis of a subchorionic hemorrhage at 6 weeks pregnant (a relatively common condition where there is bleeding between the chorion membrane and the uterine wall - this typically occurs with no known cause). It was advised that I reduce my exercise regimen and rest. Luckily, by 10 weeks gestation, the bleed had resolved, and the early diagnosis of COVID didn't seem to have any lasting effects, so I was cleared to resume my normal exercise routine. Early in my pregnancy, I switched OBGYN practices as the practice I was currently going to was out of network with my insurance, and now that I was pregnant, I knew that the frequent lab work and ultrasounds would be expensive. So, I chose to switch to a practice that was covered by my insurance. In this new practice, there were a handful of providers that you rotated through, and whoever was on call the day you went into labor was the provider that would deliver for you. I knew one of the physicians personally and scheduled all of my appointments with him as I wanted him to be the one to deliver our baby. I should also mention that at the time, I wanted an elective cesarean section as I liked the idea of being able to schedule the delivery, and I am very comfortable with the operative setting. I had a great relationship with my physician and trusted him. Unfortunately, due to unforeseen circumstances, he had to abruptly leave the practice when I was approximately 16 weeks pregnant, and I began seeing whoever was available for my routine appointments. Once I established with the other providers, my birth plan was never discussed. No one asked what my wishes were; it was assumed that I would have a spontaneous vaginal delivery. As I got closer to my due date, I felt great. I began to reconsider my desire for an elective cesarean. I vividly remember having a conversation with my husband about how I was considering having a spontaneous vaginal delivery as my body seemed to know what it was doing, and if I could avoid having to recover from an abdominal surgery, then that would be ideal. I told my husband that I would have a low threshold to convert to a cesarean section if necessary, and he was supportive of my decisions.

Fast-forward to 40 weeks gestation plus 1 day when I visited my OBGYN office for my final prenatal appointment. The physician I saw asked if I would like to have my cervix checked for dilation, and I agreed. At this time, I was 4cm dilated and 80% effaced. He asked if he could do a membrane sweep, which I agreed to, and he told me that it was likely that I would go into labor within the next 24-48 hours. That evening I began to have significant back pain and some vaginal bleeding. I called my OBGYN office and was told that some bleeding following a membrane sweep was normal, but if I was concerned, I could always go to the hospital to be evaluated. My back pain worsened, and it was clear to me at this point that I was experiencing back labor. I remained in labor at home until roughly 2 a.m. when I decided it was time to go to the hospital. At the hospital, I was 5cm dilated and 90% effaced. The nurse asked if I wanted an epidural, and I said that yes, eventually I would. She called anesthesia and told me that the nurse anesthetist would be up shortly to begin the epidural. I was surprised it was happening so quickly as I didn't feel I needed the epidural yet, but I agreed to it as the nurse shared that she liked the nurse anesthetist who was on call and trusted her. After the epidural, my back pain reduced significantly, and I was able to rest a bit, but unfortunately, my labor seemed to stall. In the morning, the oncoming physician decided that I should be started on Pitocin to speed things up. I agreed as I was ready to finally meet our baby, and my contractions were inconsistent since the epidural had started. Pitocin was started around 9 a.m., and at noon, the physician came in to check me. He told me that I was fully dilated and ready to push - but I didn't feel ready to push. I wasn't having any pressure or sensation to begin pushing. I was told this was because of the epidural and that I should begin pushing anyway. Here is when a series of unfortunate events begins. I am told to begin pushing like I am having a bowel movement. This went against everything I had read about how you should push during labor, but I listened to the resident physician who was delivering me as this was my first pregnancy, and I was unsure of what I was doing. The attending physician was in and out of the room throughout my second stage of labor because the unit was full and he had multiple laboring mothers to check in on. Because I wasn't feeling contractions, I was being told to push based on the TOCO monitor. That was fine until the monitor stopped picking up my contractions. The nurse tried multiple times to adjust the probes and turn the machine on/off, but the contractions were no longer registering. Instead of switching monitors or rooms, I was told to continue to push when I felt like I had to. I reiterated to the staff that I never felt the urge to push, so I wasn't sure when I was supposed to. The nurse placed a hand on my belly and would tell me to push whenever she thought I was having a contraction. An hour later, I was told that they could see the baby and he should be out soon. This continued for 3 more hours. It wasn't until 4 p.m. that I began to feel a pressure sensation and the urge to begin to push. Unfortunately, at this time, I was exhausted as I had been actively pushing for 4 hours straight. When the doctor came in to check on me, I told him that I couldn't do it anymore. He told me that it would be a difficult c-section as the baby was fully engaged in the pelvis. He said that he could guarantee that he could get the baby out in the next push with the use of forceps. I was concerned about the use of forceps as I knew that they could potentially cause harm to the baby. At the time, I was not concerned about myself nor did I know what kind of trauma they could cause to the mother. I asked the doctor if this was the right decision, as the baby was not in distress. He told me that he felt it was the right decision and began to prep for delivery. The NICU team was called, anesthesia came up to give me additional medication through my epidural, and the procedure began. At first, he handed the resident the forceps and walked her through how to apply them. I was not comfortable with this and asked if the doctor could do the delivery instead. They agreed. There was no additional consent, no further information about the risks of the procedure, etc. The doctor placed the forceps, and with my next contraction and two pulls, my baby was delivered at 4:58 p.m., 4 hours and 58 minutes from the time I began pushing. I remember feeling such relief that he was finally out. He cried right away, had wonderful APGAR scores, and both myself and my husband were excited to finally meet him! I then heard the doctor asking the nurse for suture material. I asked him how bad my tearing was, and he said third-degree and that I had lost 750ml of blood. I made a concerned face, and he said “You weren't going to get away with anything less than a third-degree tear despite forceps or not based on your stature.” I remember thinking, wow, that is such a horrible thing to say, and also, if you felt that way - why did I even attempt a vaginal delivery in the first place? Once again, the doctor began to talk the resident through how to suture the laceration. I kindly asked if the doctor could do the repair instead of the resident, and they agreed. 30 minutes later, the repair was done, and I asked my doctor what I should expect for recovery. I knew very little about third-degree tears, and he reassured me that because I was young and healthy, I should be fully healed in a few weeks. At this time, he mentioned that I had also experienced a thrombosed hemorrhoid from extended pushing and recommended I use a sitz bath when I got home. That was the extent of my education regarding a third-degree obstetrical laceration.

Once my epidural wore off, I began to experience significant perineal and rectal pain as well as an unbearable amount of rectal/pelvic pressure. I requested a colorectal surgery consult for the thrombosed hemorrhoid. The colorectal surgeon saw me later that day and told me that he would typically recommend draining the thrombosis, but he did not feel comfortable intervening so closely to my tear repair. The following day when the physician came in to discuss discharge planning, he asked how I felt, and I said terrible. I said I was surprised that I felt this much pain, and he replied, “You are?!” I was unable to stand, walk, or even sit without excruciating pain and was concerned that things were not right. Yet again, I was reassured that this was typical postpartum recovery and not to worry. During my stay, no nursing staff or physicians assessed my injury. It wasn't until the day of discharge that I asked my physician to look at the repair. He did and told me that it looked okay and I was cleared to be discharged. Once I got home and had the chance to grab a mirror and take a look at the tear myself, is when I knew that things were not okay. The laceration was open and poorly approximated (the edges didn't line up well). It was obvious that the suture material had either come undone or that part of the laceration was never closed properly to begin with. I immediately called my OBGYN office, and they offered me an appointment for the next morning. That morning was brutal. I was in an extreme amount of pain and was discharged home with only over-the-counter medications for pain control. I remember standing up and feeling like I had no pelvic support, as though there was a heavy, throbbing pressure sensation and my organs were going to fall out. I had to lie down in the backseat of the car on the way to the appointment. A nurse practitioner examined me and was concerned that my sutures dehisced (came undone). She called in a physician to take a look and he reassured me that although the sutures were no longer intact, the wound would heal by secondary intention as long as I kept my legs approximated and didn't put any tension on the tear. The doctor said to give it at least 6 weeks to close. I wasn't satisfied with that answer considering if a post-operative patient came into my clinic and their sutures had come undone we would either re-suture the wound if appropriate or take the patient back to the operating room to repair the closure. At this point, I didn't want to be difficult, so I took the doctor's recommendation to wait 6 weeks and went home to heal. The pain and pressure made it nearly impossible to walk or stand. I would spend the majority of my day in bed with my legs together to not put any tension on the tear. I was unable to sit properly which made it impossible to breastfeed. I tried multiple breastfeeding positions and even attempted to exclusively pump, but unfortunately, due to the extreme pain, I was unable to tolerate the attempts to breastfeed, and we switched to formula. This was beyond disappointing. A few days after being home from the hospital, I experienced my first episode of fecal incontinence. I felt the urge to have a bowel movement and began to make my way to the bathroom; however, before I made it all the way there, I had already begun to go. I was horrified. After this incident, I started to research severe obstetric lacerations incessantly. It was then that I discovered all of the potential complications and lifelong deficits that can be experienced after a obstetrical laceration. I called my OBGYN to inform them of what had occurred and again, I was reassured that this was fairly normal in the postpartum period and that it should resolve with time. At this time I asked my OBGYN if I should be referred to a urogynecologist and was told that it wasn't necessary since I wasn't having any urinary symptoms. I altered my diet, weaned off of stool softeners, and began taking Metamucil. It didn't work. I again experienced another episode of fecal incontinence and this time I called the colorectal surgeon's office to be evaluated. Colorectal surgery saw me and told me that I had weak but adequate rectal tone and that the incontinence was likely due to the trauma I experienced and that my symptoms should improve with time. I went home feeling defeated. I was terrified that my life as I once knew it was gone. How was I supposed to go to work, exercise, travel and resume normal activities with the fear of incontinence?

It was then that I entered a very dark place. I was unable to properly care for my newborn son. I could not pick him up, carry him, or take him for walks in the stroller. My husband was responsible for everything and this made me feel an extreme amount of guilt. I am an independent person so I felt devastated by how much I needed to rely on my husband. I spent multiple hours a day researching obstetrical lacerations, trying to find some glimmer of hope that there was going to be light at the end of the tunnel. The information that I found was grim and left me feeling hopeless. 4 weeks into postpartum I was still unable to walk more than a few feet due to pain and pressure. I absolutely could not sit and had to spend the majority of my day side lying on the couch or bed. This was far from the postpartum experience that I had imagined. I had no appetite and lost a substantial amount of weight. I began to cry multiple times a day, replaying the delivery over and over in my head. I wondered what I could have done differently, I regretted not having a c-section and I perseverated on how I wished I could go back in time and do it all over again but differently. I felt like a burden and was convinced that my symptoms would never improve. My family and friends became concerned and reached out to a psychiatric nurse practitioner who agreed to a telemedicine appointment and I was started on an SSRI to help with my mood. I didn't feel like I was suffering from postpartum depression, instead I felt like my physical injury was causing my poor mood and if my physical condition improved then my mental health would too. After 5 weeks postpartum, with little to no improvement, I decided that I wasn't getting enough support from my OBGYN office and needed a second opinion. I was fortunate that my husband had some connections at a nearby hospital and I was able to make a urogynecology appointment for the following week.

Consulting with urogynecology was the best thing that I could have done. My physician was incredible and for the first time, I felt heard and understood. She took the time to listen to my story and was the first physician to tell me that my symptoms were not normal and also not something that I had to suffer with. She was unhappy with the wound healing and felt that the wound needed to be revised. She began me on topical estrogen cream and scheduled me for an anorectal ultrasound due to my bowel complaints as she wanted to evaluate if I would require a sphincteroplasty. Fortunately, the ultrasound did not show a significant defect that she thought would benefit from intervention. She suspected that my muscle weakness was from the tear and felt I needed more time to heal and recommended pelvic floor physical therapy once I recovered from surgery. I went into surgery at 6 weeks postpartum. While under sedation she was able to better assess the extent of my injuries. After surgery, she told me that the injuries were more extensive than she had appreciated in the office. She found that the vaginal and perineal connective tissue were significantly thin such that the external anal sphincter was exposed. I underwent a posterior colporrhapy, perineorrhaphy, and revision of prior obstetric laceration.

Recovery was not easy and did not come without complications. Week 1 I spent the majority of my time resting in bed. I was still in a significant amount of pain, although this time I was discharged with the appropriate medications for pain control. I was incredibly diligent about keeping the area clean and dry as I feared infection. During week 2 of recovery, I began to notice some redness and swelling around the repair. I contacted my doctor and she saw me right away. She wanted to be aggressive with treatment as I was at high risk for wound infection due to the initial tear and secondary repair so she started me on antibiotics. After a few days, the redness resolved. During week 3 of recovery, I noticed a small area of suture that was beginning to separate. This sent me into a spiral and my mental health once again declined. I was doing everything that I could to keep the area clean, avoid tension, and prevent further injury, so why was I experiencing wound breakdown again? My doctor saw me right away and agreed that some sutures were coming undone and began me on two additional antibiotics as a potential cause for wound breakdown could be an infection. I was on 3 different antibiotics over 2 weeks and despite probiotics, my stomach was a mess. Having to use the bathroom became a trigger for me as it increased my pain and reminded me of the trauma that my body had gone through. My physician continued to see me every week to check my wound healing. It wasn't until approximately 6 weeks after my surgery that I began to see some improvement. The repair was beginning to close and my pain was reducing significantly. For the first time in nearly 3 months, I felt hopeful. I thought things were starting to turn around for me but then seemingly out of nowhere, a new area of wound breakdown appeared. I was feeling discouraged but continued to care for my wound to the best of my ability. To optimize wound healing, I began using Medihoney on the repair during the day and the prescribed estrogen cream at bedtime. Slowly, over the next few weeks, the area finally closed. I continued to be in a moderate amount of pain, was unable to sit properly, and brought a pillow with me everywhere I went. However, now that my incision was fully closed, I was able to begin pelvic floor PT. My physical therapist felt that the pressure sensation was from the large amount of scar tissue I had not only in the perineum but in the posterior vaginal wall and external anal sphincter as well. I worked with pelvic floor PT once a week. During this time we focused on scar tissue massage, Kegel exercises, diaphragmatic breathing, and trying to reconnect the brain to the body. I made it a priority to do scar tissue massage daily as well as begin to stretch and apply tension to the area once I was cleared to do so by both my physician and physical therapist. This is when I began to notice the most improvement. My body was deconditioned from multiple months of immobility. I slowly started to reintroduce exercise and weight training. The more I moved my body the better I felt both physically and mentally. I had not suffered from bowel incontinence in months, although I was still experiencing bowel urgency. I began to trust my body a bit more and had less fear about leaving the house. My life finally started to return and my mental health improved remarkably.

I am currently 5 1/2 months postpartum, 4 months post-operative, and still very early in my recovery. I feel 85% back to baseline and am now able to pick up my son, take him for walks, exercise, and feel comfortable leaving the house for extended periods. I still experience some bowel urgency but continue to work on this with my pelvic floor physical therapist. I no longer have pain with everyday activities. The rectal pressure sensation is still present, although decreased appreciably. My husband went back to work a few weeks ago and in the upcoming weeks, I will return to work as well. My life is starting to feel more like mine again. I still think about my birth often, but I have slowly been able to accept that this injury was not my fault and that I cannot go back and change my outcome. The physical and emotional toll of this experience has been immense. I have faced not only the physical pain and discomfort but also the grief and trauma of a birth experience that did not go as planned. I have also had to navigate the healthcare system, advocate for myself, and educate myself about my condition, as many healthcare professionals were not familiar with the complexities of obstetrical lacerations and their potential long-term effects. While I am grateful for the medical interventions that have helped me on my path to recovery, I am also deeply saddened by the lack of awareness and education surrounding severe obstetrical lacerations and their potential consequences.

The path was arduous, filled with setbacks and moments of doubt, but with every step forward, I reclaimed a bit of the strength that had been buried beneath the trauma. To anyone reading this who is grappling with their birth experience, know that you are not alone. Your pain and feelings are valid. Reach out for help, share your story, and let the support of others guide you through the healing process. Just as I have found strength within this group, I believe you can too. Thank you for allowing me to share my journey. May our stories remind us that healing is possible and that from the depths of trauma, we can emerge stronger than we ever thought imaginable.