36 weeks and appointment to discuss delivery in 2 days following 3rd degree tear last time...

[PenguinArmy]

but not sure what I want. I'm not afraid of labour (despite last one being back to back, having asthma attack due to GnA, and lasting a fair few days) and am apprehensive about a CS however

I don't want my PFs to be any more ruined than they are. I could never get back into running proper as it would be constant need to wee and in order to go for runs I would not drink before hand often end up with cystitis after the run.

Controlling gas was a issue

Regarding bowel movements it is hard to say as I think I have IBS so therefore if I needed to go, I needed to go suddenly and without warning. Who can tell if it's worse of not (although I seem to have trouble with wiping now - sorry TMI)

Ever since the start of the pg PFs got drastically worse (is this a permanent or temporary thing). I feel like I had some troubles before hand but they were manageable - just and I just don't want to risk further damage.

I am not well read though, is the labour likely to cause problems (yes I know a lot of damage is just due to pg)

Sorry for the ramble, any info appreciated. I want to go in a bit forewarned etc. as obviously there isn't much time left (due to various life circumstances birth has yet to be discussed in my care largely due to only recently arriving back in the UK). I'm worried that I want a CS but would be too chicken to fight my corner

TIA

[KellyKettle]

Penguin I can understand how stressful this is for you. I had a 3rd degree tear and was left with problems which are mostly ok right now but my colorectal surgeon believes will worsen as I age. I am 35 weeks pg and have researched this to death.

Here is a quick summary of what I have found:

Risk of repeat tear - 5-7% which is a bit higher than average but acceptable to some.

Avoiding instrumental delivery, epidural & labouring on your back are your best bet for avoiding another tear but it can't be guaranteed.

If you have little control of flatus and are anxious about worsening bowel symptoms if you tear again, I believe that is reason enough to opt for a CS this time and I don't think many obstetricians will disagree with you - if even only for fear of litigation.

Even if you were feeling scared of labour or scared of worsening your bowel who could judge you after what happened last time? If you would feel safer with a CS then don't be afraid to say that to your consultant.

Recovering from a 3rd degree tear and the accompanying bowel/flatus problems was a deeply traumatising time for me and I don't think anyone who understands what that's like can judge you for wanting a cs.

I think they'll agree to you having a cs. Everyone I know who has had a 3rd degree tear has been offered cs for subsequent births.

Good luck and let us know how you get on at the hospital.

[KellyKettle]

p.s. if you don't want to come across as confrontational then just ask about assurances that you won't tear again, rates of repeat tear - are you higher risk (yes) and what the long term prognosis would be for your bowel if you did tear again, would it mean a greater risk of incontinence?

If they can't answer all of these with "no higher risk than last time, symptoms won't worsen anyway" etc then I would ask if it would be less risky for you to have a cs (in avoiding incontinence). I don't see how they can conculde otherwise.

[KellyKettle]

*conclude

[Georgimama]

I have recently had a ELCS for second baby due to 3rd degree tear in first delivery, although luckily I have had none of the problems yours has given you. I must say I feel I have made a much quicker and less painful recovery from the ELCS than from the 3rd degree tear (except for driving, I couldn't drive for 4 weeks after ELCS and drove within a few days of first delivery).

It's hard to advise as surgery carries its own risks of damage to bladder and bowel, although from what I can tell the risk is lower with an elective procedure than an emergency.

[KellyKettle]

Georgimama Congratulations on the birth of Dc2!

Did you have to "fight" for your elcs or where the hospital quite open to the idea?

[Georgimama]

No fighting at all. When I had my booking in appointment with the midwife (at about 10 weeks) she said it would be best for me to see the consultant to discuss previous delivery and the problems. I went to see him (a registrar in the event) who just offered me an ELCS on a plate. I was so surprised and had always thought a CS was something I wanted to avoid like the plague that I said no. Then after discussing with DH and my mother and other people I began to wonder if it would be better to have the ELCS after all. I did a bit of research and decided I did want the ELCS after all. So with a red face I told midwife I had changed my mind and could I see the nice doctor again and she made another appointment with registrar for me at 36 weeks. C section was booked there and then.

[KellyKettle]

Well, thats good to hear. I'm glad it went smoothly for you.

I hope it is as straight forward for you penguin

[PenguinArmy]

thanks for the replies I was a bit disheartened when I first checked in this morning.

I have a MW appt. today, first time I see her as someone else booked me in. Although DD is due some jabs just before hand so it could be a flying visit. Appt is on Thurs and it's been stressing me out not knowing one way or another. Of course the only person who knew of anyone said that she had to really fight for her CS, I have a feeling it comes down to the consultant you see. Hopefully DH can make it with me

[eagerbeagle]

I am 36 weeks pg with DC2 and had severe 3rd/4th degree tear with DC1. DC1 was on the large side (over 9lb), poorly positioned and in distress. Labour was fast and natural but combination of events out of anyone's control led to the tear.

Recovered well from it with lots of rest but was off my feet for the first 2 days and walking difficult for about a week and uncomfortable for about 6 weeks. Probably took a good 3-4 months before started to feel normalish again.

Although no real continence issues apart from uncontrollable trumping for teh first month or so I also have the "wiping" issue and found it more difficult with continence when I became pg again (the violent morning sickness certainly didn't help and I was a sorry sight puking my guts up with wet knickers)

Anyway midwife referred me to consultant at 12 weeks and was offered ELCS straight out if I wanted one. Was told to think it over and go back at 34 weeks with decision. After much thought have decided to have the ELCS which my consultant said she thought was the best option. I can't face my bits being ravaged like that again and feel that I was lucky to have recovered as well as I did and don't want to put that at risk. Also I can feel the strain on the scar now which is tight and can be sore (2.5 years later) and the thought of it having to stretch gives me the weebles.

There is guidance on this on the RCOG website and NICE on this which you might want to research.

[golemmings]

I think it depends on the hospital. Our local hospital will ONLY offer a CS if there is an overriding medical need for it. Despite a 3rd degree tear last time, I've not pushed for a CS this time around; I'd like to try a natural birth again and do it better. (DD was compound presentation, I'd had enough and just pushed and pushed and pushed until she came out despite the MW's instructions to wait for the contraction).

I've been told that the risk of a compound presentation isn't any higher and there isn't a much greater chance of a tear.

I'm currently 39+6 and certainly getting leakier.

I'm with eager on the morning sickness with wet pants though and after last time I found that, despite doing the exercises my PF fell apart when my periods returned.

he first time I went for a run with a period due I found every time I changed from walking to running, I was leaving a small trail around the village. The local dogs must have been confused with this new territory marking. It really put me off going to the gym or a class. I don't mind wetting myself on a back lane in the dark where nobody can see and where I can come straight through the door and into the shower but I'm not prepared to do it in a lit hall full of people!

[PenguinArmy]

It didn't go so well.

At first I saw a male registrar (name badge said trainee locum) who seemed of the opinion that since it was VB birth last time I shouldn't have a CS. Felt like he was really dismissive and I burst into tears. He kept going on about physio and that my problems came from not having it last time (was never offered where I was) and that nearly all women were fine by 3 months. Missing that fact that I wasn't. He also said that they could make sure I have a experienced midwife but couldn't answer any q's. Also going on about the fact that it wouldn't be fixed, well I know that, but I don't want it getting worse.

I asked could I speak to someone else e.g. physios since he was so certain that they would fix everything and then he got huffy saying 'I'm the registrar and a ndecision needs to be made' At this point I wasn't aware I was being offered a choice judging by his attitude. So he went and got a female consultant who was really sympathetic.

She has referred me to the VBAC MWs to discuss a birthplan and answer more of my questions and then if after that I want a CS she'll be happy to do it and I just need to tell the MWs and they'll sort it out. It seems like this place does take heed of concerns in the birth plan.

I'm still really confused as to what I want though and feel like I need 'permission'. Just the first guy made me feel terrible and kept insisting my problems weren't from the tear. Still upset now :(

[Georgimama]

You don't need permission. Birth is not an olympic sport, you do not need to do it "well". If you want the elcs keep pushing for it. The registrar sounds like a twunt - he can't guarantee anything about a vb - the delivery suite could be packed to the rafters on the day. Don't worry about what anyone thinks just do what you think is best for you and your baby.

[largeginandtonic]

I had a 3rd degree tear with my dd1. This was after a previous c section for twins.

The 3rd degree tear was worse pain initially but overall the recovery was much quicker than the section.

This made me sure that i wanted a VB next time. Luckily for me i did not have any ongoing issues with the 3rd degree tear. The next birth and the 4 after that have all been VB, most at home. A 2nd degree tear is standard for me but not tons of stitches.

I understand your fear. The thing is you will never know how the next birth will go. It could all go smoothly or for very different reasons could be complicated.

The Reg you saw does not sound helpful at all. I would call your midwife and ask to speak to another consultant about it asap. You need to know you are safe and comfortable with the people looking after you! How can you relax otherwise.

[PenguinArmy]

thanks for your responses

I'm less emotional now and feel clearer. If it hadn't have been for my DH I think I would have just 'given in' two minutes into the discussion and then gone into labour really scared (which would probably lead to issues in itself).

The consultant has already referred me to post-natal services so I can start to tackle current issues. She suggested that the VBAC MWs could help me write a birth plan that made it clear all my concerns in a way that would attract attention to them. I would have no idea how to write one on my own. Since these MWs work at the hospital I presume they'll know about how labours typically work there so I should be able to get a feel for things. A few of the things the consultant said suggested that it worked differently (in a good way) to my previous place I gave birth in.

Regarding the permission bit I do have a problem with doing what 'authority' tells me unquestionably, even if it's not what I want. If they had said in your case we recommend a CS i would be happy and have no problems but feel like to say yes I would be going against advice. Although in hindsight I can see that the consultant gave me that as much as she could. She talked about re-empowering me over the birth and was actually really reassuring, just I was a crying mess by that point .

At least I have a plan now, if I feel like the MWs ware reassuring I'll give a VB a go (I also feel like MWs will have my needs more in mind for some reason rather than CS targets) otherwise I'll ask for the CS. Because I've been in transit for so long, everyone Ive come across have said they won't discuss delivery with me so now it all feels a bit rushed (the registrar wanted the decision there and then)

sorry end ramble, good to articulate some thoughts and thanks again to everyone

[Thumbwitch]

So glad you saw someone considerate and sane in the end.

Go and talk to PALS about that registrar. Because although your outcome may have worked out for you this time, he is a menace to every other pregnant woman who comes his way and he needs a sharp attitude readjustment pronto. He needs retraining - the only way that can happen is if people complain about his attitude in the first place. It will also help you to strengthen your own position on this if you get angry with this self-congratulatory twat - he knows nothing about your problems and situation and refused to listen properly - and if you need further incentive, just imagine him being there whenever you go into hospital.

[PenguinArmy]

First of all, I want to say if it wasn't for MN I wouldn't have kept asking until I felt like there was a resolution of some kind especially to KellyKettle who made me think about how to phrase things and think about exactly what answer I wanted

Also of course there was a typo in OP - gas was a issue but now is something I have no control over

This issue is still going round in my mind so I'm continuing to ramble on here Now it's a mixture of decision making and also confusion as to why I got so upset. I'm not sure what I would complain of, nothing was overt. Just frustrated at his apparent lack of logic (his reasoning suggested no-one with a 3rd degree tear should ever have a CS) and his inability to answer the Q asked (there was only so many ways I could rephrase it). As you say thumb there was the not listening but also not asking.

I've thought of more q's to ask to the MWs, how do odds change if you go over/are induced. Also I've realised people keep going in about the odds (and 1 in 20 sounds a lot), but it's just about that. It's a case of have the consequences changed (in my head it has)?

[BigBadBear]

PA sorry you are going through all this. I went through a similar thing with DD2 - nasty labour with DD1 (induction at 42 weeks, epidural, 7 hour second stage, ventouse delivery, third degree tear, nasty MWs throughout) that left me traumatised. I was lucky in that my local hospital is a centre of excellence for thrid degree tears, as I developed a fissure on top of the repair, and eventually ended up having it re-repaired a year later (after a year of crying everytime I went to the toilet for a poo).

I was hellbent on a CS for DD2, as I simply didn't want to run the risk of it all happening again. But I saw the gynae people who reassured me that I was as good as new, and the chances of it happening again were the same for someone to whom it had never happened (I felt very proud of my pelvic floor at this point!). I also balanced the definite consequences of a CS (a lot of pain short-term, not allowed to drive or lift etc) against what may or may not happen with a vaginal delivery, and decided against a CS (much to everyone's surprise).

When it came round to it, I was induced at 39 weeks due to severe SPD. I had been very anti-induction again due to my previous shocking experience, but figured that at least I knew the worst case scenario, and I was prepared for the sheer brutality of childbirth (which I wasn't the first time - who is?!). I ended up with another ventouse delivery, and all in all it wasn't a great experience (left at second stage for far too long again but with no epidural this time, awful MWs) but no tear at all. Nothing. So a much better experience for my body, and in a way, it helped get rid of some of the trauma of the previous time, because I felt a little bit more in control.

So I guess what I am saying is that once you have had a tear, another tear is not inevitable. Maybe it is worth asking for a gynae referral so they can check everything out and say what state you are in? If you are so scared from last time that you want a CS, then you can ask for one, and they won't refuse you (particularly if you cry - this is sad but true). But do make a list of the pros and cons of each so you can be sure of the decision you make.

And good luck x

[Thumbwitch]

In terms of tearing, I was told by my lovely MW (the one who cleaned me up after the birth) that giving birth on your LHS (as I had done until the last push) was one of the best ways to avoid a tear. I don't know if she is right - and if she is, why the fuckety fuck they don't TELL more women that - but wanted to pass that useful bit of info on for anyone reading this who does have a VB post 3rd degree tear.

[KellyKettle]

From Royal College of Gynaecologists:

"There were no systematic reviews or randomised controlled trials to suggest the best method of
delivery following obstetric anal sphincter injury. The risks of a subsequent vaginal delivery after
third-degree tear were examined in four studies,5,49,53,54 which showed between 17% and 24% of
women developed worsening faecal symptoms after a second vaginal delivery. This seemed to
occur particularly if there had been transient incontinence after the index delivery.53
All women who have suffered an obstetric anal sphincter injury should be counselled at the booking visit
regarding the mode of delivery and this should be clearly documented in the notes. If the woman is
symptomatic or shows abnormal anorectal manometric or endoanal ultrasonographic features, it may be advisable to offer an elective caesarean section.

Penguin I had a meeting with my consultant last week and she was almost insistent on my having a section. I want a homebirth this time, even with the risks of tearing. My decision is made slightly easier because my surgeon has told me that having another vb couldn't worsen my long term prognosis (my tear was misclassified and only partially repaired) so in that respect I have nothing to lose, except perhaps facing another tear, repair and bringing the inevitable forward by a few years.

In your case, if you have problems controlling flatus now then I'd say you were symptomatic and therefore should be considered for a cs.

I completely know what you're saying about a second vaginal birth healing emotional wounds from last time, that's certainly what I am hoping. I would just like for them to give you the choice and outline the risks and benefits of each option.

Induction is something I would avoid like the plague if you are considering vb. It tends to confine you to the bed for monitoring meaning you find it more difficult to have an active birth - positioning baby, gravity helping things along etc. If they use syntocinon the contractions are reportedly more difficult to manage naturally and so you might be more inclined to opt for an epidural. Obviously this will put you on your back and mean that, come the pushing stage, you'll be pushing through your perineum and increases your likelihood of tearing.

In your situation, I would print of the RCOG guidelines, meet with the vbac team and ask for the risks and benefits of an elcs and a vb. Most likely it is something which will be decided by a consultant in the end I think. How many weeks are you now? How do you feel about vb now?

[Georgimama]

Echoing what kellykettle said, my hospital follow a similar protocol for VB after severe tear as for VBAC - that is to say they won't induce you if you go late, it's an ELCS at 10 days after term due to the problems of escalating intervention which can be caused by induction.

[PenguinArmy]

Right, thought I'd update

Following appointment with the VBAC consultant MW, I agreed to try a VB but with some caveats that CS would happen if...

Woke up in labour early Tuesday morning (about 3:30) never went more than 5 mins and the contractions never lasted more than 60secs. Got through until DH and DD got up. Got DD ready, made sarnies and headed to labour ward, was 4cm much to their surprise so they let me stay in and phoned DM to get her to come up to look after DD. Initially got sent up to MLU but then bounced back down to general labour at 9:30 and caught a MW fresh on duty with no ladies to look after.

As I was on my own and had the history of not great birth last time, she was really communicative and reassuring. DH came in at 11:40 having passed DD onto DM and I was 9cm with just GnA. At this point they broke my waters to speed the last bit up and get me through transition.

Right at the end after umming and ahhing I had a small episiotomy (didn't know they used scissors and not a scalpel, I might have sworn at this point ) and he came out quickly. Once he was there, they very much got me to pant through the contractions and let my body do the work, plus before hand got me to do what I felt I needed to do rather than being told when and how to push.

DS arrived delivered by the doctor who did the cut (she was very nice). I feel like I actually saw the birth this time. He even tried crying when only the top half of the head was out. They applied pressure to the perineum and kinda pushed him up and away. Waited until cord stop pulsating and then they clamped and DH cut it. Labour this time was recorded as 3.5hrs (versus 24 from admittance at 4cm last time and already been at 3 cm 24hrs previous to that with contractions). So DH made the last 90 mins.

Physically I was able to move straight away although was suprised at how pain I was in the first half an hour. The stitching didn't quite go to plan, MW missed two apex so another had to come in undone it all and started again, but she gave me back the GnA for that and the after pains. After 90 mins got to sit in the chair and feed DD (last time it was ages before DD fed, nearly a day, and because of being taken to theatre I didn't try for a while either).

I am so much more mobile and in less pain than last time. I think not having a frame of reference nor speaking to other people, it was a long time before I realised my physical recovery was not quite the norm. It's probably a mix of having slept the previous three nights and not having the same physical trauma.

Thank you to everyone who helped get my head in the right place. Although I have to admit once the contractions started I was wondering why the hell I chose to do this again and not go for the CS Have seen the physio already and have a follow up in 6-8weeks. I feel it helped a lot having someone to speak about the exercises with and not just being given a leaflet.

Sorry for the long ramble and thanks again :)

[PenguinArmy]

He was 6lbs 10 3/4oz, nearly 2 oz lighter than his older sister but 11 days earlier