Birth options after 3rd degree tear with incontinence

[How2GetItOut]

Have obviously name changed for this.

I?m 17 weeks with my 3rd and had a third degree tear with DC2. (No apparent reason ? head pushed out very slow, in good position, and baby almost 2 pounds lighter than older sibling, who was nearly 10 pounds and delivered ventuose on back with only 2nd degree tear). Tear was supposedly on the more minor side of third degree.

Tear seemed to heal up fine, in terms of pain, comfort during sex, etc. However, I suffered mild faecal incontinence for several months. Almost forgot about it, except that now I?m pregnant again it is back. This got me to doing research, and I have only recently begun to realise the potential risks of subsequent vaginal birth.

After my tear, I was never given any advise on excercises, referral to phisio, symptoms to look out for, etc. We did move house 8 weeks after the birth, but I would have thought I should have had some sort of advice/exam before then.

I am now concerned about having a vaginal birth. I really don?t want a csection (only traumatic thing about DC2?s birth was the spinal and stitching afterwards!). However, I am very concerned about worsened incontinence. I could deal with what I went through after the last birth ? it was relatively mild compared to some other women, and ultimately it stopped. However, I am much more concerned about worsening or prolonged symptoms, or symptoms that pop up some years down the line.

My consultant has offered me ELCS but not given a recommendation either way. If I went based only on her facts/figures, I would go for a vaginal birth hands down. However, based on my own research, covering medical literature as well as testimonies of mothers who have also considered birthing options after 3rd degree tear (and medical advice they have received!), I feel she has significantly downplayed the risks.

I recently saw a midwife who advised I ask consultant for referral to colorectal surgeon. I am due to see phisio next week. Got in early due to a cancellation. Can anyone who has had phisio after tear related faecal incontinence tell me how effective it has been?

For those who have had ultrasounds and/or other tests to assess your own personal damage, who does this? Is it an ob/gyn, or colorectal surgeon? Was it something you asked for, or was it part of normal follow up?

Have also heard that it is the actual pregnancy itself rather than the delivery that can exacerbate incontinence problems, so if this is the case, ELCS may not actually avoid future problems. Anyone been told this, and if so, by who?

I just want to make sure I am seeing all the right people and getting the right info/advice. When this baby comes, I will have 3 under four, and have no family in the UK, so ELCS is not an easy choice for me.

If you?ve got this far, thanks for reading!

[backinaminute]

I'm in a similar position. I am 32 weeks pregnant with my second dc. I had a traumatic first delivery which ended up with a failed ventouse, forceps, epistiotomy and 3rd degree tear. I didn't have any faecal incontinence (until I became pregnant again).

I was planning on having a vaginal birth but when I spoke to the consultant at 12 weeks she said that the risk is that if I was to tear again in the same way they wouldn't necessarily be able to repair it as well as last time. I've thought about it lots and I think I am going to have the ELCS.

I started a similar thread a few months to ask about what other people have done and their experiences after a 3rd degree tear. I'm not sure how to link a thread though. It's a really hard decision.

[shelley72]

I had third deg tear with my first. Was sent to see a consultant early in second pg who could see no reason why I shouldn't have a straight forward vb. So I booked for a home water birth as midwife said this could minimise tearing. As it turned out, dd was breech and so I ended up with an elcs. The recovery from the section was far easier than the vb and the tear. I know a section isn't to be taken lightly, but i was up and about much quicker after the elcs.

[shelley72]

Just to add op, I wasn't given any exercises, physio, exams either. Maybe it depends on where you live as to how much post natal care you receive

[trafficwarden]

It's a difficult decision but it sounds like you have not been followed up appropriately either. I will outline the recommended guidance and it may help:

All women who sustain a 3rd degree tear should have follow up at a designated perineal clinic with facilities to perform anal scans and manometry (measures muscle tone). If this is not available they should be referred to a colorectal specialist and/or specialist gynaecologist. Depending on the findings they can give you a better idea of whether further damage would be likely or not and if a CS is recommended.

You say your symptoms are milder than others you have heard of and feel you could cope with this again - here you might be offered dietary advice, constipating/regulating agents and physio and most importantly follow up by the specialists.

The risk factors you should avoid are big baby, possibility of shoulder dystocia, prolonged labour, OP position and difficult instrumental delivery - all of which are difficult to predict accurately.

It remains a very personal decision and should be based on the fullest information about YOU, not a hypothetical woman. Most Consultants are sympathetic and would offer CS as a matter of course.

If you do decide to go for a vaginal birth, you should have an experienced MW and episiotomy is not found to be of any benefit.

Finally, as a MW I have helped more than a few women give birth after 3rd degree tears. None of them had perineal damage anything like they had previously and plenty had no tears at all. When labour wasn't progressing smoothly the decision to proceed to CS was made earlier rather than later in the hope of avoiding any of the factors I listed earlier.

I hope this helps and you can note down questions to ask your Consultant/MW/Physio. If you can access the Cochrane database it has all the evidence condensed and reviewed.

Good Luck!

[trafficwarden]

Forgot to say there are different recommendations for people who have significant continence issues and may need surgical repair but from your post I felt it might be information overload. Happy to elucidate if anyone wants the info.

[ICompletelyKnowAboutGuineaPigs]

This is very informative thread and thank you trafficwarden for your info.

I had a pretty bad (apparently) 3rd degree tear with DS and then with DD I was advised to have an ELCS because of the risk of permanent and irreversible damage. Safe to say this really scared me! I did suffer with some faecal and bladder incontinence after DS and was referred to women's physio for electrical stim, biofeedback etc and was worried it would all happen again but would be worse.

After deciding to go for ELCS I saw another consultant who said that they can scan the area to look at the quality of the scar tissue and make a more informed decision. Anyone had this offered? I am now pg with DC3 and hoping for a vbac but not sure how to begin proceedings with consultant as not sure what the 'leeway' is.

[trafficwarden]

The scans and manometry can be really enlightening. Imagine you have a scan done with a probe a short way up your bottom. On the screen you will see the typical black and white scan picture. If the repair you had is strong and functional you see a complete white circle of the sphincter muscle. If the repair is not as well healed the circle of muscle is incomplete or narrower in certain areas. It really can be a revelation, so those who might have no particular symptoms can see how the scar tissue might be very vulnerable and more prone to further damage.
In practice, I have never met anyone who had symptoms of incontinence who chose to go for a vaginal birth. Having an elective CS might not prevent any problems further in the future but it would protect the tissue of your perineum in case you needed repair surgery in the future and the surgeon would have more to work with, if you see what I mean. Women who have needed repair surgery after the initial suturing are recommended to go for CS or some choose to complete their family before having the extensive repair.

[How2GetItOut]

Thanks, ladies, for all the very helpful info, especially trafficwarden.

My consultant was definitely thinking short term - when I brought up my concerns of post-menopausal problems she brushed them aside and said we wouldn't be worried about that, just about what happens after the birth. Easy for her to say!

You all have confirmed my thoughts that I need to have an ultrasound done, and possibly other tests. Oh, joy!

Traffic - I'd be interested in hearing a bit more about degrees of incontinence and recommendations for each, if you don't mind. I'm not even familiar with the terminology, as my consultant was first medical person I've discussed this with.

Re phisio, should I be expecting some possible invasive/embarassing treatment at next week's appointment? Biofeedback and electric stim don't sound too fun. Just want to be prepared.

Thanks again!

[TheObscure]

Hello

think I can answer this one!

Had 3rd/4th degree tear with forceps with my 1st followed by hemmorhage and 3 hour stitch up, didn't even get to see by baby for 3.5 hours. I effectively have a brand new anus!

I won't lie, it's been horrific in places, have had Norovirus 5 times In 2.5 years and have been incontinent with that. Have also suffered incontinence in day to day life which is extremely hard especially as I now worry every time I go out BUT I went on to have no. 2 naturally within 31 mins of getting to hospital, consultant pushed for planned CS but for some odd reason I dug my heels in and refused.

I did have 2 nd degree tear with no. 2 But it was not painful once I'd had a local to stitch. I walked out of the hospital feeling great the same day.

In fact my continence issues seem to be better since no. 2 weirdly, I feel tighter, though I still have issues.

No one can tell you what to do and when I was in labour I remember screaming I wanted that cesarean but ultimately I can honestly say my 2nd degree tear with my 2nd has caused no extra problems, in fact I'm more continent than before

Don't feel bad whatever you choose, you've been through hell, this one will be better xxx

[ICompletelyKnowAboutGuineaPigs]

I found biofeedback & electrical stimulation ok - not pleasant but no painful. It basically consisted of a small probe inserted into my bottom and then a small electrical charge would stimulate the muscle on my behalf until I could do it by myself! It was very useful for me and I have no lasting issues now apart from a slight wee dribble on the trampoline!

Trafficwarden do you think the advice re the cd would be the same if the initial post-birth issues resolved with physio. The only thing I still have a slight issue with is lack of sensation in the muscle when trying to do pelvic floor contractions. That's why I found the biofeedback so good and so I do the exercises on the basis of memory rather than feeling.

Also, what is the difference between the initial sighting and the full repair? How would I know which I have got?

Sorry to hijack the thread OP but this is the MOST (and most useful) info I have got about 3rd degree tears and their implications on subsequent birthing since DS was born. He's 6 in 2 weeks and I've had DD since then!

[ICompletelyKnowAboutGuineaPigs]

I found biofeedback & electrical stimulation ok - not pleasant but no painful. It basically consisted of a small probe inserted into my bottom and then a small electrical charge would stimulate the muscle on my behalf until I could do it by myself! It was very useful for me and I have no lasting issues now apart from a slight wee dribble on the trampoline!

Trafficwarden do you think the advice re the cd would be the same if the initial post-birth issues resolved with physio. The only thing I still have a slight issue with is lack of sensation in the muscle when trying to do pelvic floor contractions. That's why I found the biofeedback so good and so I do the exercises on the basis of memory rather than feeling.

Also, what is the difference between the initial sighting and the full repair? How would I know which I have got?

Sorry to hijack the thread OP but this is the MOST (and most useful) info I have got about 3rd degree tears and their implications on subsequent birthing since DS was born. He's 6 in 2 weeks and I've had DD since then!

[trafficwarden]

I'm on a different time zone to UK so I'll come back tomorrow with answers. Using IPad in bed, husband grumbling!

[trafficwarden]

Masterclass in OASIS (Obstetric Anal Sphincter Injuries)

The different classifications are:

3a - less than 50% of external sphincter torn
3b - more than 50% of external sphincter torn
3c - internal sphincter also torn
4th degree tear - when there is a 3rd degree tear with disruption of the anal epithelium.

Once a tear of this severity has been identified you should automatically have been taken to theatre and had suturing/repair done under epidural/spinal to ensure complete pain relief and good lighting. That is VERY important. That is what I mean about initial suturing and may be the only treatment you require. Prognosis after this kind of repair is that 60-80% of women will be asymptomatic after 12 months. If there continues to be issues then a secondary repair by a colorectal surgeon should be offered. That is a significant operation and there would be counselling involved so you should know exactly what was going on. After this type of surgery all births would be recommended by CS.

The part that nobody is going to be able to predict is who will have a complete recovery with no incontinence issues and who will have life changing issues. There is a long running and very supportive thread in this board for women with sphincter injuries. This is why it's so important to have the appropriate follow up and discussions about your mode of birth dependent on the findings and your preference.

Management of subsequent pregnancies:

Scenario 1: Initial post birth repair >Perineal clinic >Ultrasound and Manometry OK > Asymptomatic > Avoid traumatic delivery, experienced MW/Doctor, episiotomy of unproven benefit > If big baby, OP position, slow progress in labour > offer Caesarean Section.

Scenario 2: Initial repair > Perineal clinic > Ultrasound and Manometry > Minor symptoms (in the woman's opinion) > Conservative management with dietary advice, regulation of bowel action, pelvic floor exercises and biofeedback with specialist Physio (important) >offer CS but if symptoms resolve and no damage found then carefully supervised vaginal birth could be attempted without increased risk of damage.

If on scan a defect of more than one quadrant (quarter of the circle of sphincter I described before) is present or squeeze pressure is reduced then risk of incontinence is increased and women should be offered CS.

Scenario 3: Initial repair > Perineal clinic and testing as before > History of faecal incontinence with sphincter defect and reduced pressure > offer secondary repair and recommend CS for all future births.

Perineal massage has been shown to reduce the incidence of perineal trauma so worth looking into that.

I hope I haven't gone into too much detail but it seems communication is a large stumbling block in maternity care and if you can get this kind of info when you are not stressed, in pain, embarrassed or just plain exhausted then you have time to consider and hopefully you can ask more questions and make a more informed decision.

All this information is from reputable sources (Cochrane database, NICE guidelines, RCOG publications).

[ICompletelyKnowAboutGuineaPigs]

Trafficwarden I love you! Thank you for all this info, not too much at all. I'm seeing my consultant in a couple of weeks and now I feel like I have a bit more info rather than feeling like I have no idea what happened to me or what could happen now.

[JemimaPrincess]

Just wondered if anyone's still checking this thread?! I am suffering with some bad symptoms and looking for some advice...

Thanks

[Insecure24]

Listening Jemima...you ok? I had a 3a tear 2.8 years ago. No faecal incontinence but a certain degree of urgency. I had in writing advice to have elcs next time.

[Deebee1983]

Hi!
I'm not sure if this message will reach anyone but came across a post on an old thread so said I would try!
I had my ds end of August, I was told I had a second degree tear which was difficult to repair as was pushing for 1.45 hours (was in birthing pool ready to push and waters broke- he had poohed in the sac so slowed it all down as had to go to birthing centre) also he had a very big head 😂
Since the birth I've recovered well however am suffering from urge bowel in continence - I don't have long to get to bathroom at all! Not had any accidents yet but am staying close to home with my 7 week old. Im very nervous and pretty upset about the whole thing. No one I know has had this issue. Midwife kept telling me to wait 3 months but if there's a missed tear then time will no heal this! I've been in touch with the hospital and have an appointment next month (seems like ages away!) but was wondering what types of incontinence people had and did Physio help? Could it be nerve damage? It's not getting better in fact it maybe getting worse. What would be classed as 'mild' incontience? I really didn't expect this as an aftermath, will definitely be opting for a c section next time I think!

[pinguina16]

Hi there!
Physio does help but it takes time. You need to do pelvic floor exercises 5 to 6 times every day until your appointment. Once you've been assessed the physio might change the types and regularity of the exercises.
I was faecal incontinent after birth for 5 days and very urgent for maybe a month. I did PF exercises 5 to 6 times a day for 6 months. I still experienced some urgency after 9 months. Things settled after one year. It is a slow process and at the moment healthcare professionals won't be able to tell you what the final outcome will be. This really made me distressed. I'd recommend having a few friends be aware of what is happening to you so they can help you emotionally but also with going to the appointments (probably every other week for a while then once a month).

Unfortunately faecal incontinence is taboo, so much so that some healthcare professionals tell women this is all normal. IT IS NOT NORMAL and I'm happy to see you've been referred. If anyone tries to minimise your problems (HCP or family and friends), be strong and ask to change physio/midwife /surgeon or take a little distance for a bit (and reevaluate your relationships later).
Your midwife mentioned 3 months because it takes that long for the muscles to start strengthening (with diligent PF exercises). It is long and will make your life different to that of other mums. Be kind to yourself. This is a hidden problem and it does mean your postpartum is different to most other mums.
Hope this helps. I feel for you.

[Deebee1983]

Thanks so much pinguina16 , your reply brought tears to my eyes (in a good way!) I have told my partner and some close friends what has been happening but if I'm honest I've been trying to downplay it or make light of it as feel noone wants to really hear about my bowel issues. In reality I'm devestated that this is happening to me and cry every day about it. I was so active before- running 4 times a week now I wonder if I'll ever be able to again. I know there are worse things in the world but I'm just feeling very hard done by- did all the right things, didn't gain weight while pregnant, went drug free for the birth - no episiotomy or forceps and yet I still have this issue.
Do you mind me asking - did you have damage to your internal/external sphincter ?
I don't mind managing this issue for year, just the thought of this forever really depresses me
Thanks for the advice , I'm doing pf exercises 3 times a day but will up it now.
Really appreciate the reply, it's nice to have contact with someone who really understands
Xx

[pinguina16]

I did all the wrong things: first birth after 35, small stature, epidural.

Although my baby was small and in an optimal position, pushing never got him out. The damage was: 3 hours pushing, 2 failed ventouse, episiotomy, forceps, second degree tear, PPH (primary and secondary), coccyx pain (have to manage this for ever now), extensive scarring (that needed further surgery), severe depression.
When I had a rectal scan at 3 months postpartum, the sonographer classified the tear as 3b but when I saw the colorectal department at 6 months and had a strength test (manometry), the surgeon didn't think my tear was a third degree tear. There was a clear area were the muscle looked much thinner than everywhere else but I could see what he meant because the circle was still visible.

Waiting to be assessed is very difficult. Postpartum time is completely different to normal time. At 9 months postpartum the physio I was seeing told me it was still early days?!#@. She was right of course. Things carried on improving after that. I was fully discharged when my little boy turned 2.
You may not have a severe tear but clearly there has been some damage. Once you've been assessed they may organise a rectal scan to check.
There is a Facebook group you may want to join called 3rd & 4th Degree (or severe/episiotomy) Tear Support. Personally I'd ask my GP if you could be referred for counselling (ideally with a perinatal team or trauma team) so you can have a safe space to talk about what is happening. The Birth Trauma Association might also be able to help in the mean time.
From my experience, physios, midwives, doctors deal with the physical aspect but aren't very good at the emotional side of things. They'll be able to answer some of your questions which should help but they're not really trained with helping you process what has happened in depth. That's why support groups and counselling might be better/useful as well.
General awareness (and therefore sympathy) about these issues is lacking. Although I eventually found very supportive friends, I also had to let go of one "good fiend" who simply denied the seriousness of my injuries. I was shocked by her responses but I had quite more important things to do than prove to her I was seriously wounded so I took some distance and other people stepped in. I also faced a small but significant number of people whose reaction was "Well, your baby's fine so?".

I hope giving you an insight into my journey is useful. Reach out until you find the right people. They are out there. All the best.