Adrienne’s Story

I went into my daughter's birth expecting things to go well. My midwife told me at my last prenatal appointment that I was, "as low risk as low risk can get." I was young and healthy, and I was prepared. I knew that having a child changes people's bodies in irreversible ways. I was aware that my brain and my boobs would never be the same, but I didn't expect to end up with chronic pain and a medical condition to manage for the rest of my life.

I went into labor on my due date, a Sunday, in the late afternoon. My contractions grew stronger over the course of the evening. Following the advice of my midwife, I tried to ignore them and went to bed. Despite having regular and intense contractions on Sunday evening, I was only having occasional, mild contractions when I woke up on Monday. I was a PhD student at the time, and I actually took a meeting with my research advisors that morning. There were things I wanted their feedback on, and I felt that I could manage a brief Zoom call. Slowly over the course of the day, the contractions increased in frequency and intensity. That night, my husband and I began implementing the pain-management techniques we learned in our childbirth classes.

By around 3 am on Tuesday morning, the contractions were occurring frequently enough that we should have headed to the hospital, but they weren't as painful as I expected them to be. We called instead, and the doctor said that either I had an exceptionally high pain tolerance (unlikely, knowing me), or my body needed a little more time to get things going. Several hours later, my situation was roughly the same. We called again, and this time, the doctor suggested that I come in.

When we got to the hospital around 8 am on Tuesday morning, I was only 1.5 cm dilated.¹ Though my contractions had been regular and close together at home, they spaced out by the time we arrived. The triage nurse said that I was still in early labor and told me to come back when my contractions were more consistent and intense. Slightly discouraged, we got back in the car to head home. Shortly after leaving the hospital parking lot, I began to have intense pain in my right lower back and hip. That ride was the longest 20 minutes of my life. I was in significant pain, I had no room to move, no access to hot water, massage, or other pain management tools, and I was headed in the wrong direction.

We eventually made it home, where I labored for most of the day Tuesday. I continued to have pain in my hip and lower back, but my contractions weren't consistent. That afternoon, after some prodding from my rightfully concerned husband, I called the hospital and explained the situation. Through tears, I explained that I could not come in again to be turned away. I needed a guarantee that they would admit me if I got back into that torture chamber formerly known as my car. The doctor assured me that they would admit me based on my pain levels alone, so back to the hospital we went.

I was admitted to the hospital at 4 pm on Tuesday, at which point I had been in early labor for two days. I had wanted to try nitrous oxide before getting an epidural, but given the circumstances, I requested an epidural right away. I was dead tired and only 4 cm dilated; I knew I had a long way to go. An anesthesiologist came in to place the epidural, and he told me that it would take effect in about a half hour. I laid in the hospital bed and stared at the clock. The pain slowly faded away, and 30 minutes later, I took a well-earned nap. When I woke up around 9 pm, I was in transition.² I could feel my body working hard, harder than it had when I ran a half marathon, but thanks to the epidural, I couldn't feel any pain.

An hour later, the OBGYN checked my progress. I was fully dilated to 10 cm. She ruptured the amniotic sac and suggested that I begin pushing. The nurse and midwife, however, noticed that my daughter was still high in my pelvis. They suggested that I be given Pitocin to strengthen my contractions and then labor down, which is when someone who is fully dilated rests and lets the baby move further down the birth canal before pushing. I agreed to labor down after they explained how waiting would be beneficial in more ways than one.³ Shortly before midnight, we all agreed that it was time to push. My daughter was born 40 minutes later.

While I was pushing, the midwife mentioned that I was tearing and applied manual support to the perineum to try to limit the damage. At the time, I didn't think anything of it. In my childbirth classes, they mentioned that tearing occurs in 90% of first-time births and that most tears aren't severe. It wasn't until the midwife said to the nurse, "I can see the head through her anus," that I knew something was wrong. As soon as my daughter was delivered, the midwife came up to me and explained my injuries. I had a fourth-degree tear, which is a tear that extends from the vagina, through the perineal muscles, through the external and internal anal sphincter muscles and into the lining of the rectum. I also had a rectal buttonhole tear, an additional hole between the vagina and the rectum, that was higher up and separate from the rest of the damage.

The midwife said that they would like to take me to an OR and put me under anesthesia to perform reconstructive surgery. I was concerned that being separated from my husband and daughter would be traumatic for us all and would affect my ability to establish breastfeeding, so I asked if the repair could be done in the delivery room using my epidural. The OBGYN agreed to try it, conditional on me being able to tolerate the situation. I was told that I would not be able to feel pain due to the epidural, but I would be able to feel the tug of the stitches pulling on tissue.

The surgery took several hours, and it was uncomfortable. It took a lot of effort to remain still as the OBGYN worked. Thankfully, I had my daughter on my chest and my husband beside me, and the medical staff repeatedly comforted me as they worked. Per my request, a nurse helped me start breastfeeding while the surgery was occurring. At 5:30 am on Wednesday, I was finally transferred to the hospital's postpartum unit.

When my husband and I got to our postpartum room, we were dazed and sleep deprived. With the exception of my epidural nap, I had been awake for two whole days. I remember lying in the hospital bed with my daughter on my chest, looking over at my husband on the couch. I had the distinct thought that this experience would make or break us. In that moment, I knew that more than anything, I needed to turn towards him and not away. It was my first glimpse into the enormity of what had just happened and the effect it would have on my life.

When the OBGYN came in to check on me that morning, my first question was, "How did this happen?" She explained that my injuries were likely caused by my daughter's positioning for the birth. She was sunny-side up&emdash;facing my stomach rather than my back&emdash;and in a brow presentation. Her neck was hyperextended, and her head traveled through the birth canal at the widest possible angle.⁴

Armed with this information, I began googling, and the pieces clicked into place. I knew that the umbilical cord was wrapped multiple times around my daughter's neck when she was delivered and that the placenta was positioned in the front of my uterus. I learned that these are risk factors for brow presentations¹ and sunny-side up positions², respectively, because they can prevent babies from tucking their chins and rolling into the optimal position for birth. My labor was also slow to progress, which I learned is common with brow presentations because the baby's head sits higher in the pelvis and does not put as much pressure on the cervix as it would in the optimal, chin-tucked position.¹ I also knew from my childbirth classes that people with sunny-side up babies often have lower back pain during labor, as I did.³ Finally, I learned that delivering a baby in the sunny-side up position more than doubles the chance of experiencing a third- or fourth-degree tear.² As someone who finds comfort in knowledge, I found it extremely helpful to have a logical explanation for my injuries from the start. It gave me something to hold onto in an otherwise scary and uncertain time.

The time I spent recovering in the hospital was extremely difficult. I needed help doing basic things like lifting my daughter out of her bassinet, getting out of bed, and walking to the bathroom. As soon as my epidural wore off on Wednesday morning, I was in severe pain. I was given OxyContin for the first 24 hours, which took the edge off. My medical team, however, wanted me to transition to over-the-counter pain medications as soon as possible because opioids can cause constipation. Making that transition Thursday morning brought on a resurgence of severe pain.

My daughter was also hurting because of how she was positioned during delivery. Her neck was sensitive, and every time we moved her, she screamed. We tried to send her to the hospital's nursery for a few hours on Wednesday so we could get some uninterrupted sleep, but she was quickly returned to us because she was crying so much that she disturbed the other babies.⁵ Watching her struggle added to our pain.

Thankfully, the medical staff recognized the severity of my situation and repeatedly encouraged me to prioritize rest and healing. They were so adamant that I sit back and let other people take care of me that I began to worry about the potential complications that could occur if I didn't take things slow. In retrospect, I can see how they scared me in a good way. As a highly independent, perfectionistic person, I tend to push myself hard and avoid asking for help. It was because of their words that I knew I needed to lower my expectations for myself and lean on my husband, family, and friends.

By the time we were discharged from the hospital on Friday afternoon, my daughter seemed to be much more comfortable, and I was managing my pain fairly well by alternating extra-strength doses of Tylenol and Advil every three hours and applying topical medications and ice. The staff had encouraged me to walk a little more each day, so I decided to try walking the short distance from our room to the hospital's exit. As I slowly shuffled down the hall, leaning the handle of my suitcase like a cane, I looked up to see another discharged mom exiting with her partner. She was smiling, walking with ease, and carrying her newborn child in his car seat. I sat down on a bench to wait for my husband to bring the car around and cried.

Emotionally, I was completely overwhelmed for quite some time. I knew that I wasn't ready to fully process what had happened to me, and I was afraid to think beyond the immediate future. I wanted to know what others had found helpful in their recovery, but I felt too emotionally fragile to hear about long recoveries and complications. A dear friend offered to research fourth-degree tear recovery for me. She bought me some products that others had recommended and sent me a few videos that she thought I would find helpful or encouraging.

The rest of our family and friends also showed up to support us. My parents cleaned our apartment while we were in the hospital and took care of our dog for a month. My in-laws and friends repeatedly stopped by with groceries and meals. My husband had eight weeks of parental leave, and when he needed to return to work, my mother-in-law, mom, and friends started coming over regularly to help me with the baby.

My recovery has been slow and non-linear. It took me three weeks to be approved to drive, six weeks to be able to walk the full loop around our local Target, ten weeks to be able to get down on the floor to play with my daughter, three months to return to gentle yoga, and nine months to resume jogging. I've experienced pain from exposed granular tissue and an anal fissure, and had bowel-related symptoms including fecal urgency, gas incontinence, and minor fecal incontinence. I've struggled with sexual dysfunction and chronic pain due to muscle and nerve damage.

I began seeing a therapist who specializes in postpartum support eight weeks after the birth, and I began pelvic floor physical therapy at ten weeks postpartum. Both have been integral to my recovery. I am now a little over a year postpartum, and I would say that I am 90% recovered. Physical therapy has dramatically increased my strength and reduced my symptoms. My remaining incontinence-related issues are well managed through dietary and lifestyle changes, and my pain has lessened to the point that it is more of an annoyance than a hindrance. I have returned to many of the activities that I enjoyed before pregnancy.⁶

Emotionally, I have struggled with a profound sense of loss. In the early days, I felt that I lost out on the postpartum experience that I thought I would have. I didn't get those smiling pictures of the new family in the hospital because let's be honest, we weren't smiling. As my recovery progressed and I realized how much of a commitment I needed to make to physical therapy, I began to feel like I was losing time&emdash;time that could have been enjoyed with my daughter or used to work on my doctoral dissertation. Since a large part of long-term symptom management involves dietary and lifestyle changes, I also lost the carefree way in which I used to eat and drink whatever I wanted whenever I wanted.

The consequences of my injury, though, have not all been bad. Many of my relationships, including my relationship with my husband, have deepened as a result. I got vulnerable about my struggles and asked a lot of people to show up for me in ways that I have never needed before. Fortunately, many of them came through. Because I couldn't be and do everything for my daughter, my loved ones also have closer relationships with her than I think they would have otherwise.

This past year was a crash course for me on how to ask for and accept the help of others. Getting comfortable with this has benefited me both personally and professionally. I have also learned to listen to my body, slow down, and truly rest. I used to set goals for how many steps I took, books I read, and times I exercised, and I judged myself harshly on the basis of those purely arbitrary expectations. Since experiencing this injury, I have focused less on what I think I should do and instead learned to prioritize what I want and need. To my surprise, I still get work done, I still do all the things that I love, and I take better care of myself than I did before.

When I think back on my recovery, I can see how it was facilitated by three things: time, money, and support. When my daughter was born, I was finishing my PhD remotely. As a graduate student working on my own research, I was my own boss. I was able to return to work at my own pace, and I had the flexibility to go to physical therapy multiple times per week. I also had good health insurance and a solid financial situation. My medical treatment was affordable, and I could splurge on a therapist who cost more than my monthly car payment. Most importantly, I had immense support from my husband, my family, and my friends, and I was at a place in my life where I was ready to ask for and accept their help.

I look forward to the rest of my life with a mix of fear and hope. As I recovered and became more comfortable thinking about the future, I began to read the research on long-term outcomes for people with severe tears. Much of the evidence is depressing. Less than 20% of women aged 60 who have experienced a third- or fourth-degree tear are fully bowel-continent (meaning they can hold in all gas, liquid stool, and solid stool).⁴ On average, long-term incontinence symptoms are more severe for people with worse tears,⁵ and I had about as bad a tear as you can get.

However, I still believe that there is reason for hope. I know that I am doing what I can to better my odds of continence post-menopause. I have hope that continued research will lead to more effective treatments over time and reduce the incidence of severe tears for future generations. And, perhaps most importantly, I know that because of organizations like SOLACE, if I do experience increased symptoms, I won't have to go through it alone.

Severe tears can be extremely isolating because the symptoms are often not well understood and are considered by many to be taboo. If you are suffering alone, please reach out to SOLACE, join a Facebook support group, or ask other people you know who have given birth if they have had similar experiences. Recovery can be frustratingly slow and full of setbacks, but it is so much easier when you are surrounded by a circle of support. To my circle, I say thanks. I wouldn't be where I am today without you.

Adrienne Judson, PhD, is a labor economist whose research concerns the economic impacts of disabilities. She experienced a fourth-degree tear and a rectal buttonhole tear during the birth of her daughter in April 2024. This story was written one year later.

References

1. Makajeva J, Ashraf M. Delivery, face and brow presentation. In: StatPearls [Internet]. StatPearls Publishing; 2024.
2. Cheng YW, Cheng YW, Shaffer BL, Caughey AB. Associated factors and outcomes of persistent occiput posterior position: a retrospective cohort study from 1976 to 2001. J Matern Fetal Neonatal Med. 2006;19(9):563-568.
3. Barth Jr WH. Persistent occiput posterior. Obstet Gynecol. 2015;125(3):695-709.
4. Nilsson IE, Åkervall S, Molin M, Milsom I, Gyhagen M. Symptoms of fecal incontinence two decades after no, one, or two obstetrical anal sphincter injuries. Am J Obstet Gynecol. 2021;224(3):276-e1.
5. Everist R, Burrell M, Parkin K, Patton V, Karantanis E. The long-term prevalence of anal incontinence in women with and without obstetric anal sphincter injuries. Continence. 2023;5:100571.

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