During a vaginal delivery, the pelvic floor is exposed to pressure and strains that can damage the muscular system and its innervation.1,2 Perineal tears during vaginal delivery are classified as grade I-IV.3 Grade III-IV tears involve the anal sphincter and are called obstetric anal sphincter injuries (OASIS). In 2016, 2.9% of vaginal deliveries, in Sweden, resulted in such tears.4 Internationally, there is a reported increase in the incidence of OASIS of up to 5.9%.1

These tears are the only etiological factors associated with fecal incontinence after childbirth.5 Fecal incontinence is defined as involuntary leakage of stool or gas.6 Women who sustain these tears during their first delivery are at much higher risk of having fecal incontinence 10 years after delivery.7 These women also tend to experience sexual dysfunction, urinary incontinence, and pain to a greater extent.1,8 These symptoms are usually associated with decreased quality of life due to the impact on daily activities.9,10

The OASIS should be identified and repaired within 12 h by a trained obstetrician.3 National guidelines for childbirth care11 recommend that aftercare includes information about the injury, pain relief, wound care, avoiding constipation, and pelvic floor muscle training (PFMT). A follow-up by a physician, midwife, or physical therapist should be completed 2–3 months after delivery.3,12

Although OASIS affects many women worldwide, the scientific focus on after-care, and in particular physical therapy rehabilitation has been limited. There are differences in management regarding follow-up, both internationally and regionally in Sweden, and not everyone affected is offered a follow-up appointment.13 Several studies have evaluated physical therapy interventions to prevent or treat fecal incontinence and although the studies were of moderate to high quality, the level of evidence was low concerning PFMT.14-19 This is due to the lack of control groups, differences in training, and contradicting results.13

Knowledge concerning the experiences of women with OASIS is scarce. From seven studies with a qualitative approach, common themes emerged; psychological consequences such as anxiety, shame and fear, implications for future pregnancies, and the role of health care professionals.1,20 Women reported the need for access to appropriate service and follow-up care from healthcare professionals.1 In few studies individual interviews have been used as data collection.21,22 To obtain a deeper understanding of the experiences of these injuries, and to further develop physical therapy care, individual interviews based on open ended questions exploring what women with OASIS expect as well as their needs and wishes, are necessary. The purpose of the study was to investigate women's experiences of OASIS and the subsequent physical therapy rehabilitation process.

A qualitative design was used, aiming to gather empirical data reflecting the experiences of the participating women. It is a suitable method for exploring and gaining a deeper understanding of experiences of health issues, personal expectations, and needs for improving health care. Individual interviews were chosen, because the topic of research is a sensitive subject. The study was reported according to standards for qualitative research.23

Current clinical practice at the Sahlgrenska University Hospital in Gothenburg, Sweden, is that the OASIS injury is sutured by an obstetrician surgeon. The women are thereafter offered a follow-up, including a visit to a specialist physical therapist 6–8 weeks post-partum. During this follow-up the physical therapist examine the pelvic floor muscles by digital vaginal and anal palpation concerning e.g., function and strength, and possible symptoms related to the injury.12 The patient is given individualized advice and help with rehabilitation, such as PFMT with or without biofeedback and neuromuscular electrical stimulation.

A purposive sampling of primi- and multi-parous women was performed from the patient files among the women who had sustained an OASIS. The inclusion criterion was an OASIS (Grade III-IV injury) during labor which had been sutured, within 24 h. Women were excluded if they were not able to speak Swedish and/or if the recruiter made the assessment that inclusion could harm the participant, due to psychological problems or any other serious illnesses. Participants were recruited by the treating physical therapist who was not involved in the interviews, data analysis, or manuscript writing.

Semi structured interviews with open ended questions were used where the women were encouraged to share their experiences with the least possible impact from the interviewers’ pre-understanding. The interviewers (EJ, NS, ÅLS) were female physical therapists with varying levels of experience from newly qualified to 10 years of clinical experiences with patients with OASIS. They were not involved in any care of the participants. The other authors (AG, MFO), also physical therapists, have experience treating pelvic floor disorders, are registered specialists, and have experience in both qualitative and quantitative research. The interviews were based on questions in an interview guide (Appendix 1), developed by clinicians and specialists. The recruitment of new participants was terminated after three consecutive interviews where no new information emerged.

The interviews were conducted either at the participant's home or in the hospital, based on the participant's choice; lasted between 35 and 66 min and were recorded on two electronic devices. Field notes were taken during the interviews. The interviews were transcribed verbatim by the interviewers before the next interview took place. The interviews were de-identified so that only the interviewers could recognize the participants.

The interviews were analyzed based on Graneheim and Lundman's24 qualitative content analysis,24 focusing on the manifest content related to the aim of the study. The methodological approach was inductive as the author was looking for patterns in the collected material through an unconditional interpretation of data, based on the women's stories. To enhance trustworthiness and credibility of data, analysis was performed using triangulation. The three interviewers analyzed and coded the data, and another author analyzed a sample of the analysis. Meaning units were conducted and condensed and thereafter abstracted with codes and sorted into subcategories and main categories.24

The study was conducted in accordance with the Declaration of Helsinki and was approved by the Regional Ethics Committee for the region of Västra Götaland, Sweden, registration number: 438–16. Oral and written information about the study were provided and the participants gave their written consent.

The 14 interviews were conducted 2–11 months after delivery, data collection occurred in 2016–2017. The women were between 22 and 41 years old and had undergone 1–3 vaginal deliveries (Table 1). One of the participants had a prior grade III OASIS. The women had visited the physical therapist 1–5 times. None of them were, at the time of the interview, under any specific treatment because of the injury.

The analysis led to three main categories with several subcategories (Table 2). The categories described experiences of a difficult recovery and physical therapy interventions, but also other participants’ experiences of a safe follow-up after the injury. Moreover, some women expressed, when looking back, it wasn´t that bad after all.

They described a process from sustaining their injury and gaining insight into the consequences and subsequent needs that follow at various stages during healing. Some experienced receiving too much information, while others too little. Some women reported having received information and support as needed, while others expressed experiences of feeling lost and forgotten. The stage in the healing process when women are receptive to information may vary.

Two levels of vulnerability emerged. Partly because the women experienced concrete physical vulnerability but also based on an abstract meaning that they felt lonely and excluded due to their situation. The participants described a sudden feeling of being unprotected and embarrassed related to a loss of control regarding defecation and involuntary gas leakage.

The follow-up appointment with the physical therapist was perceived as difficult, as it reminded the women of how the OASIS had affected them. The women felt vulnerable and exposed during the pelvic floor examination. The PFMT also acted as a constant reminder of the injury.

The abstract experience of vulnerability was expressed when they felt left alone with written information at the hospital, about the injury and its rehabilitation, without proper verbal explanations by a caregiver who could answer their questions. They also felt that the information given was overwhelming, and even unwanted at times. Specifically, the physical therapy treatment was perceived as incomplete and the information about the rehabilitation was not always sufficient.

“I thought it was tough to do the pelvic floor exercises in the beginning because to me it was a constant reminder that ‘you've injured your privates during labor’. And you're supposed to do the exercises pretty often, preferably a couple of times a day, and every time it was like ‘oh well, now you're doing this because that happened.’”