Uncategorized – dr matt thyer

Private Perth Gynaecologist Dr Matt Thyer offers care at St John of God Subiaco and Mount Lawley Hospitals

Not uncommonly women may site concern about sexual dysfunction following vaginal birth. Concerns such as a lack of sexual interest (libido), pain at the entrance of the vagina, occasionally urinary or flatus incontinence, excessive laxity, reduction in sensation and pleasure. This can lead to reduced confidence with intimacy and lowered self esteem. Particularly where breast feeding is involved there is a significant reduction in natural ovarian oestrogen’s that are produced compounding vaginal tissue sensitivity, dryness and atrophy. Sleep deprivation due to parenting demands will commonly reduce libido.

Generally your Gynaecologist will recommend at least 6 months of observation, disciplined pelvic floor exercises and expectant management following childbirth to see if these problems self-resolve. A Women’s health Physiotherapist can guide your recovery in this way. Occasionally vulval or vaginal oestrogen’s may be of benefit, however caution is required in the context of ongoing breast feeding.

However despite disciplined exercises sexual function may be sub-optimal. This is because much of the pelvic floor and fascial/connective tissue damage occurs away from the obvious site of injury at the perineum and remains hidden underneath intact skin in other areas of the lower genital tract, commonly between the bowel, bladder, bladder neck and vagina. Perineal tissue melding may be also sub-optimal resulting in long term problems such as inadequate perineal support, a capacious opening of the vaginal entrance, scarring and hardening of tissues that can result in excessive sensitivity and pain.

Where conservative measures prove ineffective or suboptimal, surgery is a reasonable choice of treatment with either scar revision, perineal rebuilding, bladder neck/urethral reconstruction or vaginal repair. The primary consideration here is about further childbearing, as subsequent vaginal delivery may result in repeated or worsened damage. Some women decide to delay surgery until childbearing is completed, while others will elect for repair and consider any future birthing via Caesarean section.

There are costs and benefits to both approaches. The primary cost to waiting until childbearing is completed is the length of time taken be relieved of symptoms. There is also the argument that delivering further children vaginally will worsen lower genital tract symptoms. Conversely, recovery from pelvic floor surgery is a long process and women need plenty of support especially where parenting demands are often at their peak.

The optimal approach depends on your individual circumstances and desires. However in determining the correct approach for you it is important for you to seek professional advice, individualised to your circumstances that is truly aimed at your medium to long term benefit.

Dr Matt Thyer Private Perth Obstetrician and Gynaecologist has expertise in addressing sexual dysfunction following childbirth and regularly performs pelvic floor and vaginal surgeries to repair birth related trauma. Feel free to contact Dr Matt Thyer to help you navigate any concerns you may have following childbirth.

Delivery planning

At 28-32 weeks gestation Dr Matt Thyer discusses your delivery planning and expectations about birth. Dr Matt will also offer a discussion about birthing expectations with Tracey Steele (Midwife and Lactation Specialist) in his rooms at 32 weeks to help you understand what is likely to happen during labour and birth, or at Caesarean section, and to help you decide on your preferences for birthing such as, but not limited to, analgesia, mobility, access to shower and bath for example. Open channels of communication about your desires and concerns are key to your sense of satisfaction about the events surrounding the birth of your child. You are encouraged to discuss these issues at any point in your pregnancy when you feel ready, otherwise it is discussed as a matter of routine as you progress toward your due date.

Vaginal birth after caesarean section (VBAC)

VBAC is supported by obstetric guidelines around the developed world provided it meets patient-based, institution-based and practitioner-based safety requirements. Decisions around whether or not to try for a VBAC can be highly emotive. A reasonable plan for one patient may be very different to another and the circumstances and risks can differ substantially. For this reason it is important to seek the advice of a practitioner that has seen the risks play out during pregnancy and labour, and knows how to deal with the potentially life-threatening complications of a VBAC.

As a general approach, provided the risks are considered acceptable to patient and practitioner, every chance should be given to help you achieve a natural vaginal birth under the careful and watchful guardianship of your practitioner.

Education and support including breastfeeding after delivery

Your midwife is invaluable in helping you to establish good breastfeeding habits after delivery. This will usually start with encouragement of skin-to-skin contact and breastfeeding as soon as possible after birth. Even at caesarean section it is possible to achieve this with the help of your midwife and other theatre staff. Occasionally your paediatrician may need to keep a very close eye on your baby in the nursery after delivery. However every effort is made to allow you a first contact as soon as possible after your delivery.

A strong focus on breastfeeding is currently adopted as there are evidence-based benefits to breast-feeding your child for at least 6 months. Breastfeeding reduces your child’s risk of developing metabolic and weight issues later in life, and there is early research showing breastfeeding can “reverse” these risks for babies that were “programmed” for metabolic impairment during the pregnancy. These are amazing benefits, however sometimes it feels like there is a lot of pressure around this issue after the birth. Again, open channels of communication with the team including your midwife, lactation consultants, obstetrician and paediatrician are key to working through these issues. Your voice is most important in this process and everyone is there to support you. It is worth remembering that breastfeeding is a partnership between you and baby, and it is not always the best thing for you both especially where the difficulties outweigh the benefits.

Analgesia in labour

There are some effective options for analgesia in labour that are supported by good evidence.

The epidural provides hands-down the best possible pain relief you can be offered in labour. Unfortunately, however, epidurals are not risk-free, they affect your mobility in labour, and can increase the duration of pushing and the risk of instrumental deliveries. They do not increase the risk of a caesarean section, and this detail is well supported by good evidence. The specific risks of an epidural should be discussed with you prior to labour so that you are not making decisions for the first time under the duress of labour.

Entonox or nitrous oxide (laughing gas) can provide some mild pain relief in labour. For some it is also a great distraction from labour. However many people experience intolerable effects including dizziness, nausea and sometimes vomiting. It is an option certainly worth considering for pain relief in labour where an epidural is considered undesirable.

Warm water immersion, or a warm shower, may provide good pain relief in labour. It is also relaxing. So where it is possible, is considered safe and does not pose a danger to yourself, baby or staff, it is a great option to consider.

Other than those above, there are no known reputable alternative sources of pain relief in labour. Some people have had good experience with morphine or pethidine and TENS machines, however overall they have not been shown to be effective for the majority of people and is poorly supported by the evidence.

Analgesia at Caesarean Section

Caesarean sections require very effective and reliable pain relief. Spinal or epidural aneasthesia provide a regional nerve blockade so that your sensation is impaired below your waist thereby allowing your obstetrician painless access to deliver you child.

A spinal anaesthetic is introduced via a very fine needle through your lower spinal vertebrae and into the fluid bathing your spinal cord. The effect is very fast and effective. Conversely an epidural is introduced via a larger catheter, but stops short of entering the spinal canal, and relies on the diffusion of anaesthetic across tissue membranes to enter the spinal fluid that bathes the sensory nerves of your spinal cord. Occassionally your anaesthetist will combine these two methods to get a faster and more complete acting regional block, but also the benefit of an epidural catheter placement that can deliver anaesthetic following your operation. Each method has its benefits, limitations and risks and should be canvassed with the anaesthetist.

Rarely a general anaesthetic will be required to provide adequate analgesia for a caesarean section where a spinal or epidural cannot be sited or where it is considered the safest means given the circumstances. In this situation you will be put to sleep and kept safe under the watchful eye of your anaesthetist while your baby is delivered. You are asleep for a short time and woken soon after your wound is closed and dressed. Recovery after a general anaesthetic can take some time as you may feel a bit drowsy, but generally after a few hours you are back to normal.

Caesarean Section

The majority of patients express a preference for a planned vaginal birth unless there are strong and compelling reasons to birth via Caesarean section. Sometimes Caesarean section is medically necessary from the outset, for example where the placenta or babies umbilical cord covers the cervix. However I find it increasingly frequent, although still overall a smaller proportion, for women to elect for Caesarean section from the outset. The very personal reasons for this are varied and reflect a well thought through and considered decision as much has been documented in the literature about the risks and benefits of planned Caesarean section vs Vaginal birth.

Dr Matt feels a Caesarean section birth need not be a cold and depersonalised experience for parents whether it be elected or required. Dr Matt Thyer has developed a sterile process of allowing parents to first see their baby delivered, and then accept baby into their arms at Caesarean section provided baby has transitioned well and there are no compelling medical reasons to do otherwise. 90% of Dr Matt’s Caesarean births are conducted in this way and Dr Matt feels it really “makes the moment” and gives the parent that first touch, the skin-to-skin that is so important for bonding and breastfeeding.

Whichever birthing option you elect for Dr Matt Thyer Perth Private Obstetrician and Gynaecologist is there to listen to your desires and concerns leading up to delivery, and to help achieve a delivery that its safe for mother and baby.