Coccydynia and second delivery - what to do?

[Lunarlyte]

Hello,

During the birth of my first child in 2009. I developed coccydynia (terrible pain in my tailbone). It had been a long labour: 24hrs latent phase, 7 hours in active labour and 2 hours pushing her out. I felt the pain in my tailbone in that last hour of pushing. It was like I was pushing against the pain of my coccyx, rather than with the pain of the contraction. I would say that the tailbone pain was worse than those contractions, and the recovery from my eventual episiotomy.

It took a long time to get better. I had physio for a couple of months about 16 weeks after the birth. This, coupled with time passing, has helped the pain go from intense to more like a deep-bone-ache just sometimes.

I'm 29 weeks pregnant now and need to decide the best/safest mode of delivery. I've seen a consultant obstetrician who says that he would perform an elective CS, but he is pro-vaginal birth as there is the chance that my tailbone will be fine. He heavy outlined te cons of CS that sound very scary.

I've also seen a consultant midwife who advises a mobile epidural so that I'd my tailbone 'goes' again, I wouldn't really feel it and would be able to get through the delivery. This would be coupled with birthing positions that keep me off my back. A vaginal birth may or may not make my back worse. It dedinately won't make it any better. Midwife also said that if coccydynia re-occurs, then pain-management post-birth is key (lots of codeine like last time, then).

I just don't know what to do for the best - risk my back, or have the CS and take on board a different set of risks?

Help, please!!!

Oh dear. I sustained damage to the coccyx and pelvis (along with a whole host of soft tissue birth injuries) when I gave birth to DD 16 months ago. Can you see a consultant orthopaedic surgeon for an opinion? Obviously you won't be able to have an MRI or an x-ray (have you ever had these?) to assess the damage and the position of the coccyx accurately, but he/she might still be able to offer advice. I am seeing an orthopaedic surgeon and he is very familiar with these sort of birth injuries. Whatever you decide to do for this birth, there might be more than just physio and pain killers that could help. I have had two lots of cortico-steroid injections in the coccyx together with manipulation under anaesthesia to break down the scar tissue that had formed round the coccyx. This has helped me enormously - the manipulation under anaesthesia is more than can be achieved with physio and is guided by the MRIs.
If it was me, I think I'd go for ELCS. Yes there are risks with any surgery, but I wouldn't want to risk my back and potentially create more problems. My orthopaedic surgeon said that in some cases of coccyx displacement that don't resolve, they need to shave the end off the tip. To me that sounds like a bigger deal than an ELCS.
If you are in London, I can recommend my bloke, if you like.

Thank-you so much for your advice, and I'm sorry to hear about the injuries that you sustained from the birth of your baby.

Annoyingly, I was not referred for an MRI at the time of my physio, despite the physio suspecting that I might have partially displaced a lower spinal disc! So I'll never know if I did actually do that. I don't know what position my tailbone is in now, or whether I displaced it or bruised the tissues around it (I think I displaced it as the pain was/is deeper, as if it is the actual bone itself).

My husband is for the vaginal birth option (I think he's worried about the risks with ELCS compared to the chance that my back might be okay with a natural delivery). My mom is totally pro-CS, seems to disregard the risks and thinks the hospital are trying to sway me into a vaginal birth because of NHS funding. This conflict is also difficult for me, along with trying to make the right decision!!

I'm in the West Midlands, and may well look into contactig an orthopaedic surgeon. Many thanks for your reply again

Sorry you are facing all this conflict on top of everything else . Hmmm - partially displaced disc does not sound great. No wonder it hurt!! I am not that well versed on the mechanics of birth and at what stage you can bail out of VS and easily have a CS, so this next thought might be completely stupid. But is it possible to try a VB, and then if you feel the coccyx go like you did last time, to then have a CS? In this case the epidural would be a bad idea, as this would mean you wouldn't know what's happening (and in any case the offer of an epidural seems like a bit of a red herring - yes you don;t want to have that agony you experienced last time you gave birth, but you really don;t want to end up with further damage to your spine). Although, even if this is possible, you'd be putting yourself in the situation of EMCS which carries risks that ELCS doesn't.

What are you worried about in terms of ELCS? Have you discussed these risks and how likely they are in your particular case?

Good luck.

Yes, I see what you mean about the epidural being a red herring; I have thought this myself, but I am trying to think it through nonetheless. I think from the midwife' perspective, she's viewing ELCS as a last resort, and trying to plan a course for natural birth that takes into consideration the possibility that I'll feel pain in my coccyx again. She's right to say that this would affect my confidence, as during the labour I wouldn't want to feel that pain again, knowing it's implications this time. Ignorance was bliss last time! I would be frightened if I felt pain in my tailbone again during the labour and perhaps panic at what I'd have to deal with post-birth, as well a dealing with agony there and then! The consultant midwife is not against me having an ELCS, but she has said if I can avoid cutting into my uterus, then I should. I guess that comment is playing on my mind.

In terms of what worries me about ELCS, it's mainly the increased risk of haemmorhage which could lead to hysterectomy (I'm 29 and we may want more babies in the future. Wouldn't want a premature menopause just yet, either!) My obstetrician feels that due to my age and sound general health, combined with the fact that I have already delivered successfully vaginally, that Id be a goid candidate for another VB. My feeling is that he's looking at me as a clinic statistic, and the coccyx problem, which may or may not worsen, is a lesser risk (to him) than the risks of ELCS. That's my impression, anyway.

The hospital where I'm due to give birth is a huge birth unit: the particular obstetrician I'm seeing performs 3-4 cesareans a day and I think the hospital itself sees one hysterectomy during CS once every 6 weeks on average. I don't know whether this is through ELCS or EMCS. I would think that makes a difference but of course, cannot assume. It's also the increased risk of death to the mother (yikes!) and then less serious stuff like a longer hospital stay/longer recovery time. I want to be back doing my usual thing with my eldest daughter, as well as with the new baby.

Of course, lifestyle disruption would ensue if I damaged my back again. Crikey, I'm going around in circles a bit, aren't I?! This is why I'm finding it so difficult to make the decision! Thank-you so much for picking up on this thread. I'm truly grateful for the advice and ideas that you've put forward, as just writing this stuff down is helping to clear my mind :) Thank-you x

God, it's so hard, isn't it? I think in these cases it's key to get as assessment of the actual risks in your own particular case. I mean, the risk of hysterectomy is present with CS. But for an ELCS, in an otherwise healthy woman who has an unremarkable pregnancy, the risk may be miniscule. Personally, I think the risks of CS tend to get talked up, whilst the risks of VB (either in general, or for a particular woman) get ignored. But that's me talking from my own bitter experience! If I were you, I'd get that referral to an orthopaedic surgeon who is well versed in birth injuries and get an opinion. Seems that this is what's missing from the current picture. You have a MW, who's not anti-CS, but who recommends not cutting the uterus if you can help it. You have an obstetrician who says that you've successfully delivered vaginally, and should be capable of it again (although I'd question the 'success' of it - sure you go the baby out, but you sustain possibly quite significant structural damage to your back in the process). But what you don't have at the moment is someone who can give an opinion of the risks of VB for your back. If you get that opinion, no matter what your decision is, it might help you with your DH and your Mom - you're going to end up going against what one of them thinks you should do, and more medical advice and information you can throw at the one who disagrees with your decision might help them to butt out and keep quiet be supportive of your decision.

Good luck and if you need a rant or to bounce ideas, please do be in touch! XX

"she has said if I can avoid cutting into my uterus, then I should. I guess that comment is playing on my mind."

Those kinds of graphic comments are intended to play on your mind and I think it's very irresponsible for a consultant midwife to do that to someone in your position. Scary, emotional images are not what you want to be basing your decisions on. Your spine matters as well as your uterus and she knows nothing about the state of your spine. An orthopaedic surgeon could just as easily describe the risk of future spinal surgery as 'cutting into your spine' - which would be equally accurate but equally unhelpful.

"the hospital itself sees one hysterectomy during CS once every 6 weeks on average."
Please don't let anecdotes like that influence you either. A large hospital will always have what sounds like a large number of hysterectomies simply because they deal with the highest risk cases and the largest numbers of women. Statistically it doesn't tell you anything about your individual risk. EMCS is much riskier than ELCS, but more importantly, ELCS which are carried out because of problems with the mother's health will always have worse outcomes than those carried out on low risk women like you. Your consultant should confirm that for you.

The new NICE guidelines are a good place to look for proper information on the risks of planned CS vs. planned VB because they've reviewed all the relevant studies and interpreted their statistical significance. They found that the risk of early postpartum haemorrhage is less with a planned CS than with a planned VB; the risk of hysterectomy due to postpartum haemorrhage is increased with planned CS compared to planned VB, but only from 0.01% to 0.03% and the quality of the evidence supporting that result is very low. The studies show conflicting results on the difference in the risk of maternal death - one of the 3 studies actually showed a greater risk of death with planned VB -and conflicting results on the overall risk of hysterectomy.

Here's a link to it: publications.nice.org.uk/caesarean-section-cg132/appendix-c-planned-cs-compared-with-planned-vaginal-birth.

As far as recovery times go, the usual statistics just don't apply to you - an average difference of a few weeks in recovery times won't make the slightest difference to you if you end up with a permanent and intractable back problem.

If you haven't had an MRI and haven't been seen by an orthopaedic surgeon, then it seems to me that your obstetrician can't possibly know how serious or otherwise your back condition is, how CS or VB might affect it, and therefore really has nothing on which to base their advice as to which option is best. Seems very irresponsible to me so I wouldn't be relying on him to give you the best advice to be honest. In your shoes I'd be getting myself referred as urgently as possible to the kind of orthopaedic surgeon that cardamomginger recommended. One that isn't familiar with birth injuries might not be of huge help to you. Good luck!

Sorry crossposted with cardamomginger and am really just repeating what she said!

Lunarlyte, I am in exactly the same situation. DD was born 4 years ago and my coccyx still hurts when I sit for long periods of time. I am now 28 weeks pregnant and every time I have tried to explain my situation to midwives and consultants they have been incredibly dismissive and said I must go for VD. The more I think about it the more I think I should have an ECS but, like you, I can't quite make up my mind. Let me know what you decide and good luck!

Wow, thank-you all for your detailed, well-measured and sympathetic responses :) I sat and read your posts last night and was blown away! (Sorry if that sounds corny). It's such a relief to hear your reasoned responses concerning ELCS.

Cardamomginger: I think you have a very good point when you say that the risks of CS are played up against the risks of VB. The cynical side of me thinks that I'm being encouraged to go for a VB by the hospital to keep costs down; that my ELCS request is being put down to 'Maternal Request' almost feels like the pain that I went through with my first labour, delivery and subsequent recovery time is being undermined. And, you are bang on when you problematised the success of my VB. It wasn't as straightforward as my discharge summary would say ('Slow progress' and 'maternal exhaustion' are on there - nowt about my back).

Sioda: Many, many thanks to you for your input. I don't think that you were repeating Cardamomginger's post. Rather, it was useful to hear similar lines of thinking and your use of statistical data has helped me to think in less panicked terms should I choose an ELCS.

You're right to say that the consultant has no idea about the state of my coccyx. He seemed to dismiss the idea that the birth itself caused the coccydynia. Instead, he supposed that it was due to softening ligaments as a result of late pregnancy. Again, this is evidence of how he might be generalising me, rather than looking a my specific case (which include the notes from my physio, who said that the back problem was most likely caused by childbirth). Now, I did have generalised lower back pain towards the end of my first pregnancy, but only coccydynia once I was actually birthing her. Its very different pain! That said, the consultant said he'd support my decision if I opt for ELCS (a condition was to speak with the consultat midwife) but I think I might have to argue a little more if I actually call to book the cesarean. I remember the midwife, mentioning her subsequent correspondance with the obstetrician, said he was 'reluctant' to perform an ELCS on me. Under the new NICE guidelines (assuming the hospital has adopted them), he'd have to refer me to an obstetrician who was willing? Backtracking a sec, can he change his mind once he gave a conditional 'yes'? (And met those conditions. He also gave me the phone number to his secretary should I decide on the surgery).

Sigma: I'm so sorry to hear that you, too, are in the same situation! I started this thread because I've been agonising since I spoke with the consultant over mode of delivery - that was 9 weeks ago. It's on my mind a lot and now I'm in my last trimester, I'm at the point where I just want to make the decision so I can 100% enjoy this last stretch. I'm going in circles talking about it with my husband, as I think tw consultant scared the living sh*t out of him, and my Mom is pro-ELCS but for worried reasons, which makes her advice unreliable (love her though I do). Sorry, I'm digressing. What I've done today is called my physio who greatly improved my coccydynia and sciatica (forgot to say that I developed that, too) to ask him what he thinks. He has promise to call me by this evening, so I shall keep you all updated. I will also post about my eventual decision, as well as how everything goes post-birth.

Thank-you all again so very much. I would never have dreamed that a website could be so useful xxx

Sioda, forgot to ask if you'd mind keeping me updated about your decisions re. mode of delivery. Are we only one week apart, EDD wise? (I'm 29+3, EDD 23/4/12). Hope that you manage to come to the right decision, too x

Blaming baby brain here, meant to direct that Q to Sigma! (duh!)

I got to speak with the physio who helped me a great deal following my daughter's birth. He wasn't able to to provide me with specific answers, but the conversation was nonetheless useful.

He said, as my coccydynia was greatly improved, that this was a good sign for a vaginal birth, which could be improved only by having had zero pain with it over the last 3 years. That I have had coccydynia puts me at a higher risk than someone who has never had it before of developing it again (obviously).

A vaginal birth could be a good option as the stomach muscles would not be cut via this option. As the 'core' stomach muscles support the back, I would be at an advantage here.

A long pushing stage would greatly increase the likelihood of re-injury, though. The shorter the pushing the better. However, this cannot possibly be predicted, nor can my lower spine's ability to hold out. He used an interesting analogy: he said that it's like trying to decide whether a footballer with a Pre-existing hamstring injury is match-fit. He might be okay day-to-day and in training/warm-up matches, but you'll never know if the hamstring will be strong enough to play a 90-minute match. The physio said that although my back is 90% okay now, the enormous strain that labour puts puts on the lower lumbar region might test it.

The bottom line according to the physio (who specialises in spinal problems) is that if my primary concern is my coccyx, then an ELCS it should be (weighed up against the unpredictablity of VB). But he said that, as well as the risks of the surgery and potential complications, my back will be made very vulnerable for a while due to the extra weakening of the abdominal muscles through pregnancy, then surgery.

He said not to rush to make the decision now as I still have about 6 weeks for it to be made. There should be another 6lbs or so of weight gain by then, plus an even bigger baby, the combination of which may make the decision for me (in that the area may become more painful). Or, it might still hold up fairly well, in which case I might want to try VB.

He added that he would not recommend a full epidural or VB as I would not be able to know if damage was being done. He wasn't ableto comment on the mobile epi as he didn't know enough about it.

Anyway, that's the latest x

Glad you had a good conversation with him. If I were you, I'd still see an orthopaedic surgeon though. I take his point about the stomach muscles being knackered through CS and that they would not offer protection to the back for some time. Yes, the muscles will take time to recover and rebuild, but they will after vaginal birth too. And if you have a CS your pelvic floor will be less damaged, and pelvic floor is crucial for providing stability and protection to the coccyx.
I take his point about reduced pain being a good sign, but if you haven't had any imaging done, no one knows what damage you originally did and I don't think someone can give a proper assessment of whether VB is a good idea or not. You mentioned the possibility of dics displacement? Doesn't sound good. And no one can say for sure, without imaging, that you didn't fracture it.

Sorry - got to go. DD is fretting for me and DH is a bit that I'm on the computer... XX

Hello, just thought that I would post an update as I have been to see a chiropractor today (I decided that this would be prudent as a spinal specialist might be able to help me make up my mind one way or another).

I'm 31 weeks into my second pregnancy now, and am now feeling that my ligaments are softening in my lower back. I have recently had some dull, niggling discomfort in my coccyx.

In short, the chiropractor and I discussed my previous injury and she examined my spine. She too, thought that my coccydynia had been caused by the pushing stage of my labour on 2009; she asked whether I had pushed before being fully dilated, and I think I must have as I read somewhere on my notes in ths past that I had an anterior lip to the cervix. The chiropractor said that this would have caused a contraction of the pelvic floor before everything was 'ready'. As some of the pelvic floor ligaments are attached to the coccyx, this would have pulled the tip of my tailbone inward, making the birth canal smaller. As I pushed for at least another good hour after the first twinge of coccyx pain, then the damage/inflammation gets worse.

After spinal examination, she said that my pelvic ligaments are indeed soft, but that around my coccyx is tight and sinewy, suggesting inflammation.

That I've had problems with my back with a previous labour puts me at a very high risk of damaging my spine again. She said that, as the coccyx is attached to the pelvic floor, that I risk further damaging that area, which could mean coccyx re-injury, or bladder incontinence, or prolapse.

An ELCS would preserve the pelvic floor, but would obviously weaken the abdominal wall. However, she pointed put that a) the way the surgeon cuts and b) the way the musculature is sewn together again, allows for those muscles to knit together again. Yes, they'll be weak and will need to be strengthened eventually, but that this will be possible. My sense is that the chiropractor was informing me of damage control to the coccyx/pelvic floor, at the expense of the abdominal muscles.

If I was to go for a vaginal birth, potential damage is being kept to one area, but it's the extent of the possible damage that is a concern.

Like the physio, the chiropractor thinks I'll really need Pilates exercises to get me back to strength post-birth in terms of core strength.

I certainly feel more informed now, especially as I didn't know that the coccyx is attached to the pelvic floor. My mind's not made up yet, but I'm wondering if I'd be mental now to go through with a VB ...

Thanks again for all of your advice x

Glad you've had some more input and some pretty sensible input, from the sound of it. You know what I'm going to say, so I won't say it !! I think she's bang on that whilst the abdominal muscles will be cut, they should knit together more easily, whereas a damaged pelvic floor could be disastrous and could be much much harder to get back. I'm now 12 weeks after my colposuspension (CS type incision) and I'm building up my abdominal strength nicely. I'm not back to where I was pre-surgery, but the strength is there and I'm able to do more each week. Really hope it works out for you XXX

Hi Cardamomginger, thanks for getting back to my post. Do you mind me asking what a colposuspension is? I haven't heard of that before. I'm glad to hear that you are recovering well, and it is encouraging to read other women's experiences of ELCS on other threads on this site. The more I think about it, the more it seems like an ELCS is the way to go. I am just so appreciative of all of the advice I've received on here so far xx

Blimey Cardamomginger, just googled the procedure that you had - I'm assuming that it was performed to correct damage caused by your baby's birth? I hope that everything works out for you, too, and that you make a total recovery x

Blimey indeed ! Yes, it was to repair the front vaginal wall prolapse and the urinary incontinence. I also had a uterine suspension at the same time to repair the uterine prolapse. So far that all seems to have gone well. I am still waiting for a rear vaginal wall repair and a massive repair of the deep pelvic floor muscles. In terms of rebuilding strength, the ripped pelvic floor and prolapse is the stuff that's going to be a challenge, not the cut abdominal muscles.

Oh and 10 days ago I had more injections/manipulation to the coccyx. I know I sound like a stuck record, but you REALLY don't want to end up like me!! X

I am so, so sorry to read about the extent of the damage that your body sustained (and is still going through, considering your surgery and future surgeries). I was wondering about the details of your baby's birth? Was it a long labour? Did you push for a long time? Did you have an assisted delivery? What sort of physical build are you? Not that this has anything to do with the wreckage of your pelvic floor. More that, as I am tall and slim (5'8" and usually between 9st and 9st5lbs. I was smaller with my first pregnancy, going from about 8st10lbs to 10st8lbs) the chiropractor suggested that the narrowness of my pelvis, combined with the inward projection of my tailbone, might have attributed to the long pushing phase/baby getting stuck/instrumental delivery.

Please don't answer this if you don't want to. I perfectly understand. It would just be interesting to find out if there are any commonalities. X

2 of my friends had excellent births at russells hall; and my sister had a fab birth at QE in Brum; depending upon where you are.

I had an ELCS with my ds2 and I broke my coccyx at 71/2 months. agony is not the word.

no matter what you do you will be lying on your back, sitting in bed etc, so you need to think on. for me, the ELCS gave me a spinal block which gave lovely relief from coccyx pain.

only when you've injured that piece of bone do you realise how fundamental sitting down is in life - eating standing up, no hairdresser/cinema/ lying down at friends houses, kneeling to watch tv...

3 yrs on I still need a special cushion to drive, other than that Im ok
ELCS was the right choice for me. I hope you have a wonderful birth, whatever you decide.

btw it annoys me when they spout the dangers of the elcs...
my 1st natural birth was horrendous, I needed 2 further operations to recover ; far more expensive and traumatic and negative experience than my elcs. the dangers of natural births aren't blathered about so much are they.

More than happy to share my experiences! My problem was that I am hypermobile and that this carries an increased risk of birth injuries - apparently it can go along with a 'too tight/strong' pelvic floor (nothing to do with the amount of exercise you do/the numbers of PFE's you do) and that during birth this goes into spasm and doesn't want to let the baby out, resulting in a protracted pushing stage and sometimes birth injuries of the type I sustained. BTW - I had no idea I was hypermobile - I just thought I was interestingly bendy in certain respects and annoyingly stiff in others and in respect to other things (like my ability to click my shoulder joint in and out by just tensing my upper arm) I had no idea that other people couldn't do it too. In terms of physical type I am 5 foot 8 and my 'normal' weight on a healthy diet and with my usual exercise regime is 54 kilos. I had a horrifyingly painful birth and got stuck at 4cm dilation (pelvic floor in spasm and preventing easy dilation). I had a 2.5 hour pushing stage, which consisted of the 'good old-fashioned' purple pushing. DD was 3.4 kilos, so not at all big. And I had no interventions. I have only been made aware of the whole hypermobilty thing after giving birth by pretty much every HCP I have seen in relation to my birth injuries. Hmmmm - if you have a narrow pelvis as well.... well, you know what I'm going to say!!!
PsychicSatsuam - you are SO right about downplaying risks of VB and overstating risks of ELCS. Makes me very angry! I have a friend form Australia who is here and pregnant with DC2. She had DC1 in Australia and there they are perfectly honest about the risks of each method of delivery. Totally different from here!

ThePsychicSatsuma: How true it is about only realising the fundamentals of sitting/standing/walking once you've damaged that seemingly insignificant bone! I wince when going to the hairdressers as I know my back will ache afterwards.

The ironic thing is that my tailbone was incredibly painful after I left the consultant to discuss the merits/demerits of ELCS. I had been sitting down a lot that day (waiting for scan) then was with the consultant for an hour, sat in a hard plastic chair. My mind is pretty much made to have the operation, although I think I'll have to really force make my argument to the obstetric team before anything is agreed by them.

I'm having the baby at Birmingham Women's Hospital, by the way (it's at the same site as the Q.E). The consultant who I've seen is Mr. Alexander Pirie (just wondering if anyone might have (hopefully good) feedback about him?)

Cardamomginger: I think that your experience is a case in point that our bodies were not designed to birth babies! It just so happens that we evolved to do it the way that we do! X

If you've decided on ELCS, stick to your guns! If I were you I'd start another thread asking for feedback on the obstetrician - it'll just get lost here.
REALLY wish you the best of luck. If you're up to it, please let us know how you get on! XXXXXX