to be sick to death of getting conflicting information from these 'heath care proffesionals?'

[Gillyan]

MIDWIVES, CONSULTANTS, ANESTHETISTS! Getting really sick of all the conflicting information I'm being given. None of them seem to know what they are on about.

Saw MW yesterday and was chatting to her about birth options as I have STILL not made my mind up what to do. (I'm 32wks)

For those few souls on here that haven't heard me whinging on - I had a 3rd degree tear last time for no apparent reason, I am booked in for a section this time at my choice but still don't know if I even want it.

So far..

One MW said she would recommend an elective episiotomy to avoid a tear going into my bum and not to birth in water as it makes your tissue more likely to tear.

Consultant said - NO WAY for episiotomy as I would be more likely to tear and he suggested a water birth or happy for me to have a section.

Anaesthetist said, as it took 9 times to get the spinal in last time it would be better to have a General for the section.

When they were trying to get the spinal in I had just given birth, was bleeding everywhere and totally distressed and begged them to knock me out and was told it would be better for me to be awake.

Now I am being told it will be perfectly fine to be knocked out while still pregnant!!

He said they would try the spinal as often as I could bare

MW yesterday said they are only allowed to try 3 times and thats it??????

When I asked one MW what happens if I go into labour before the section date she said we just examine you to see how far on you are then if you change your mind and want to give birth thats fine or we just whisk you in for the section.

MW yesterday said NO WAY that will happen, she said if you go into labour before your section date they won't give you a section without a medical reason - to which I relpied, erm..what about the reason I am terrified about ending up with a colostomy bag and the consultants have already agreed I have every right and reason to have one???? She said not. Section is booked for 39 wks and I had DD at 37 so now scared I'll go into labour and my choice will be taken away from me.

WHO do I believe, getting so so fed up of this. I really don't know what to do. I spent all afternoon crying yesterday.

The only thing I can do is to go for it and just hope I don't tear as badly again. Thats it, 'hope' or maybe give birth in water...if the pool is free..if my labour is safe to do so.

Otherwise I go for the section ( if I make it to the day ) and risk having to have a general anaesthetic as they had problems getting the spinal in last time when I needed to be put back together.

What do you reckon?

And I did start a thread asking about anyone who had a bad tear last time, what happened second time but didn't get too many replies so would be very intersetd to hear your stories

Blimey another soul up late!

I think the research very much supports water as a perineum protector, but that the op's history of a 3rd degree tear means the research may not stand iyswim?

Did see research on warm water compress too somewhere......

I'm in California, so just making dinner over here! Really impressed with your research, Tree, I'm going to take a look at those guidelines later. I love mumsnet for actually throwing up research that the professionals never tell you about (or just tell you one side of!)

Ho well don't be too impressed, this ain't no literature review, just me having a google! Plus I am not forming management here, just reading around it a bit, y'know? Am bound by my governing body, being a hp myself, so I can't advise or make statements that are percieved as guidence. But I do feel comfortable pointing people towards info that might help them out a bit.

Nice has a bit on the warm compress thing.

A bit at being in California. Have you anyidea how glam that sounds to me here with unsettled bubba?

Oh, I've got the unsettled little one too. I tend to be up with him when everyone starts posting in the morning though - it gets too addictive so I end up waiting for a thread to refresh at 2am instead of getting much needed sleep! So... much the same over here, just with nicer weather! (Sorry!)

Sorry for hijacking.

gasman -

OP said: "Anaesthetist said, as it took 9 times to get the spinal in last time it would be better to have a General for the section."

Regardless of what you find offensive , that is a moronic statement, not to mention an acknowledgment of incompetence - "It was so hard for me to give you the epidural last time, I think you should have a GA this time" .

If a plumber took nine tries to install a bath in my bathroom, then had the nerve to say I should have a shower in my other house because it was oh so hard for him to put in a bath last time, I wouldn't forgo the bath. I would find another plumber.

And you know what - I wouldn't care one bit if all the plumbers in the world find that offensive

Woah, Is this what The NHS is like in posh other parts of the country?!

I've seen my midwife about 3 times during my whole pregnancy, never a doctor/consultant/anesthetist.

All labours are different hun, maybe just go with what seems the most appealing and see what happens. I never even glanced at my birth plan 1st time round and am not going to bother writing one this time at all. Am sure you'll be fine,

news.bbc.co.uk/1/hi/world/africa/662472.stm

It must depend on the individual patients anatomy as to how easy it is to get an epidural in, not everyone is the same.

To stretch the bathroom analogy, at least there the plumber can look at, and measure the bathroom in advance to see what its dimensions are. I imagine that the anaesthetist has much less idea in advance of how easy it will be to put in an epidural.

Hi Gillyan,
Without knowing the full details surrounding your last pregnancy and the delivery circumstances yours does sound like an unfortunate and unusual case. Assuming last time was a first pregnancy and you did n't have a particularly long 2nd stage of labour, other than it being a first labour you have none of the commonly associated risk factors associated with a 3rd degree tear.
The guidelines from the Royal College of O&G advises that "all women who are symptomatic after a 3rd/4th degree tear should be given the option of an elective CSection". Asymptomatic women are usually encouraged to consider vaginal delivery.
The problem is that there is still a lack of good quality research in this area with regards to the best course of action in future pregnancies bearing your individual circumstances in mind (damage sustained despite no obvious risk factors).

Unless you feel strongly about having a vaginal birth a CSection is the only guaranteed method of avoiding further anal spincter damage (but it has its own risks). A mediolateral episiotomy may reduce the risks of further sphincter damage but also cannot prevent it.

With regard to anaesthetic for a CS a GA is usually the last option when the anaesthetists cannot insert a regional block (spinal/epidural). Again not knowing the exact circumstances of your last delivery/postpartum problems it is difficult to advise on this. It may have been a relatively inexperienced anaesthetist or the circumstances which could have contributed to the difficulties experienced. This time round if you have been assessed by a senior anaesthetist I would take their advice.It may be that they feel that with an elective CSection (when you are not in pain and losing blood at a rapid rate) that a senior Aneasthetist will be successful inserting a spinal/pidural. At worst if they are unsuccessful with a 1st or 2nd attempt then they have early recourse to considering a GA.

If you were keen to go for a vaginal delivery then if you were my patient I would encourage you to labour in the pool but not to deliver in it. I feel that your second stage should be out of the water where the midwife could have utmost control in:
1)Guarding the perineum
2)Controlling the delivery of the head
3)Performing a medio-lateral episiotomy if that was deemed necessary (yours especially is not a case where you want any suboptimal placement of the episotomy due to wet slippery gloves/perineum!).
I would suggest forceps delivery not be contemplated and if anything other than a low cavity assisted delivery was required then they consider resorting to a CSection in labour.

It is a difficult decision but bearing in mind the relative risks and the long term implications of those risks together with the fact that you sustained a3rd degree tear without any obvious contributory factors if you were my wife/patient I would recommend a CSection but with assurances that a Consultant Anaesthetist would be inserting your epidural/spinal (assuming the anaesthetists did not feel this was contra-indicated for some other reason)!

Again as stated above raise your concerns regarding the conflicting advice you are being given so that your key specialists can come to an agreed best plan of management with you.

I hope everything works out for you. Do let us know how you get on!

FYI the RCOG guidelines & Pt information on this can be found :

"here"
&
"here"

I'm just lurking here as I had a 3rd degree tear with dd (but she was 9lb 5oz).

Thank you SymConsultant for such an informative overview. Mumsnet is rather fabulous.

Gillyan, I hope it all goes well for you.

ooooh - sympatheticconsutant - what you said with bells on! Isn't mumsnet handy like that?!

growlyg (a sympathetic GP who was going to try to compose a response only to find a much better one already done!)

I would also agree that being unable to site an epidural in a distressed and active person does not equal incompetence - sorry Cote but you are wrong here and a tad offensive to the excellent anesthetists out there. But then I guess you don't do the job so don't understand ......
It makes me laugh that you think you can compare the competence of an anesthetist with that of a plumber. Unfortunately that just shows your ignorance.

I am not an anesthetist btw but have worked with plenty of them down the years.

I had a 3rd degree tear with both of my DS's - DS1 was 9lb 6oz and face up and I had to have an episiotomy but with DS2 he was only 8lb 6oz and no episiotomy.

I would urge you not to consider a home birth as despite the conflicting advice you'll need these people around if you go down the same route I did. The one bonus was I was only in labour the second time for 4 hrs!!!

SymConsultant - My understanding (from anesthetist meeting at hospital last week) is that a spinal block for CS is different than an epidural, because it is a single shot and not a drip. Does that mean it is easier to do?

chilly - Plumber story was an analogy. Do you know what that means?

You can laugh all you like, but I would still not go straight for GA for CS just on the word of an anesthetist who took 9 tries to put an epidural in me last time.

By the way, an anesthetist gave me an epidural while in throes of labour last time, with seconds between contractions. He cleaned the area, then waited for contraction to pass. Then he did local anesthetic, and waited for the next contraction to pass. It took another 1-2 contractions to complete the procedure, but he managed to put the epidural in no problems.

Yes, I know there are many good anesthetists out there. It just doesn't sound like OP's is one of them, and it's not offensive to the whole profession to say so.

Cheers sympatheticconsultant.

It is my understanding that spinals are less technically difficult due to space the anaes. has to find. They are therefore quicker. [generalisation, but hey what ya gonna do]

The idea of labouring in water then delivering ob land is good imo - the research does not enlighten us as to how water births affect those with prev scars. Hmmm. Dunno how feasable it would be though - it would take determination on your part op, to get yourself up and out during the second stage. But that is for you to decide/wait and see at the time.

On the side issue of the analogy - I think the whole body is very like plumbing, many aspects of medicine are to do with flows, pipes, blockages, tubes, and so on.

It will always rankle a bit with hcp's who hear of a fellow hcp being deemed incompetent, based on one sentence or example. Here on mumsnet were I to decide a mother was too incompetent to feed her child because she once, say, gave her child food poisoning [crap analogy sorry], I would get flamed. I do not know the mother, her circumstances, I don't know the child and how it came about, I don't know if the food was in date, why she thought it was ok and so on and so on.

So I disagree, I think on this evidence it is a bit offensive, but not cardinal offence. Should try being a mw around here! .

It is not just that it took him 9 stabs to place an epidural, but that he then gives this as a reason why OP should go for GA in a CS.

cote
It took 9 goes to get the spinal in last time. Her back presumably hasn't changed.
We don't know the full story as to why (if there is a why) it was so difficult. Therefore there are good grounds to believe it might be difficult again.

Regional is generally felt to be 'safer' for the average woman for obstetric proceedures but the 'average' woman doesn't need 9 attempts at siting a spinal.

There are risks to having any proceedure and sometimes those risks outweigh the benefits.

However risk-benefit analysis is very individulalised so what is acceptable to one patient isn't to another.

If the OP is very keen to try regional anaesthesia again provided there are no definite contraindications I would be surprised if the anaesthetist on the day won't attempt to site a spinal for her.

However she needs to know before she gets there that there is a risk it might not work and that may still end up having a GA. Sounds like she has also been presented with the option of having a GA as a first line treatment.

Spinals involve a smaller needle being inserted further than in an epidural and whilst they are generally easier to learn to do (as if you go too far with an epidural you cause lots of side effects) they aren't easy. You are basically trying to pass a very small needle into a very precise place between the spinous processes in the back. The spaces can be very small (milimetres).

Is your argument really that OP must be a mutant with an extremely rare kind of spine that is exceedingly hard to get a needle into? Really?

Or, it is possible that meeting another (more senior, as SymConsultant said) anesthetist could be a good idea?

We don't know anything about the OP.

She might weigh 10 tonnes,
She might have a massive scoliosis
She might have had previous back surgery.
She might just have had a really shit time in her last labour and been leaping around all over the shop. All of these things may make a spinal difficult

Or she might as you so charmingly put it have a 'mutant' spine. They do exist. I've met two women who have had serial failed proceedures by increasingly senior clinicians. The last one ended up with nerve damage despite her procedure being attempted only Consultant level staff one of whom is internationally renowned (who i would willingly allow near my own back).

I did say in my original posting she should make sure she had seen a Consultant (but in general the anaesthetist in clinic is a consultant). We don't know the grade of the anaesthetist who failed last time either. Sadly procedures like this have learning curves and the fact it was a trainee may well have contributed to the 9 attempts but WE DON'T KNOW THAT.

In cases like this (ie difficult cases) most anaesthetists will document in the notes why they thought it was difficult. The person who saw her in clinic (and suggested the GA) had the benefit of those notes you and I don't.

Hi Gillyan

I'm sorry you're getting all sorts of conflicting advice - its a hard enough decision to make without all that.

I had a 4th degree tear with my DS and I elected for a c-section with my DD. The thought of sustaining more damage down there was enough to put me off going for a vaginal delivery and I was booked in for a section from when I was 20 weeks pg.

In retrospect, all I can say is that I'm glad that I chose a section, it was a much more peaceful experience! I was still under the care of the colorectal surgeons until recently - the last one I saw said that if I was his wife he would have insisted on a c-section. That made me feel easier about my decision.

Don't know if this helps or not but good luck with making your decision and whatever you decide, I hope it all goes well.

Wow, lots of chatting been going on! Thanks to everyone for their input.

sympatheticconsult thanks so much for all the detailed info - it really is great.

To try and answer a few of the things that have come up.

RE - anesthetist.

He was a senior one and when he was doing it he said he had NEVER had such a problem in all the years he had been doing them, He said he thought he kept hitting bone but then decided it was cartilidge and asked if I had done any sports that would give me a strong back. I am used to trampolune all the time and am a qualified coach.

Although in my original post I did say I was distressed and bleeding etc I sat stock still and never moved an inch each time he tried.

Re - 'posh' NHS??? I have had to see the consultant as was classed high risk becuase of previous tear. The MW suggested I have a meeting with her as she is a superviser of midwives and she wanted to pull my notes as there was also a LOT of other things that went wrong with my care before, during and after the birth. As she went through my notes with me she said booked me in to see the consultant anesthetist as she saw the surgical notes and the comments about how many times it took to get the spinal in.

The anesthetist was really lovely but when he saw me they had lost the surgical notes and he thought he would of written some comments. He was very quick to say about a GA and after I saw him I started to feel that maybe it was more so to fit round him than what was best for me. I asked if he could not even try a spinal and he said yes, he would try until either I got fed up or he did. Again, I thought well I'm not having the GS just because you get fed up of trying.

Have decided if I did go down the section route then if I had him again, and he wasn't able to get it in, I would ask for someone else and I don't think I would give my consent to have a GA. I really think I would just wait and go home and wait to go into labour.

I have no problem with GA and had 2 last year for wisdom teeth out and appendix. I just don't want to CHOOSE to have my baby like that as I missed the first 3 hrs of DD life last time. However if something went wrong and I HAD to have a GA then of course I would just be happy and grateful that whatever was done to have a happy outcome for both me and the baby.

My 3rd Degree tear was described as a 3rd degree b, which means the tear went half way through to the middle of my sphincter. The MW should me the surgical notes and the diagrams and said the tear was half a cm away from a 'c' which would of resulted in a colostomy bag at least for 3 months if not longer.

This is the bit of info that made me start to consider a section as I know it's the only way to avoid completely any further injury to the sphincter.

The surgeon who put me back together said at my 6 wk post natal chk that she'd advise a ssection next time and I am wondering if she said that as she could see my tissues were 'friable'. No way to know this and wonder if anyone could tell by looking?

It's the choices I have which are the problem, ironically. If i had a quick labour and no time to do anything or had abreech baby etc then the decision would be taken out of my hands and I know that I would be happy as long as we were both ok. I am really worried about the effect it would have on me mentally if I did end up with incontinence issues from choosing to give birth again. And likewise I feel I am giving up on my only chance of a better birth by having the section and I honestly just don't see the section as an easy option.

I know that there is just no right answer but I do agree with the sypatheticconsult that as I have been asymptamatic since the tear it is recommended that I go for vaginal.

BTW the second stage was 1hr 50 mins.

I suppose I am leaning towards vaginal delivery and trying to use the water where appropiate, give birth on all fours and breathe the baby out. And..hope the best. I suppose if I end up needing reconstructive surgery or something I will just have to try not to get down about it and know that I gave myself the best chance of the better birth.

So true what you say about the choices being problem. The pita for all of us who have babies and look after women who have babies is that we are making choices without knowing what is actually going to happen.

If I choose a yellow coat with green spots on, I am going to be wearing a yellow coaat with green spots on.

If I choose to labour, I may end up with sphincter damage, or an intact perineum.

If I c/s, I may avoid sphincter damage, or avoid a cathartic birthing experience. [Although it is possible to feel positive about birthing and have perineal damage, I say this as the op is keen to avoid iyswim]

It's pants, and it's the burden of choice imo. Though I wouldn't have it any other way.

Just believe that whatever the choices you make, if you end up with a less than ideal story to tell, that doesn't mean the choices you made were bad. I think alot of the emotional fall out from birthing stems form this, bad outcome=bad choice= my fault.

Am I right in thinking you would not go to GA for section if the spinal could not be sited? Didn't want to read it wrong iyswim?

I think, to try and summarise...

I keep thinking about the recovery from a normal vaginal delivery ( anything less than a 3rd degree tear ) versus a definate recovery from major abdominal surgery. Obviously I am lured by the prospect of the first and I think Ihave forgotton about the reason for the elective section.

I was having the section until I was told a GA may be necessary, then I started to think of the risk of tearing as badly again v's having to have a GA.

Part of the reason I don't want to have a bad tear again is I don't want to have to go to theatre after giving birth and missing the first few hrs etc, I don't want it to interupt bonding, I don't want to have to have further surgery down the line with a little baby and I don't want to have to live with a colostomy bag with a new baby. It would just plain suck! I don't want me and DP to miss the birth.

Then the MW says about I can't have an elective section if I go into labour earlier than the elective date.

I also asked MW about what it is she can do to care for my perineum i'e, pressing on it ( which another MW had said she could do and I have read about it ) and she said there is nothing she could do and all I can do is to do perinial massage! So terrified of which MW I'll actually end up with and them refusing to do what I ask.

hence me thinking I'll just go it alone on the dining room floor!

I suppose the thing that is worrying me the MOST is the risk of further damage to my bottom and how it would impact my life so I think I just need to accept a section is the only way to know this won't happen and I won't end up with horrible MW's like last time....so the only problem now is the anesthetist. I ams eeing the consultant at 36 wks for a pre-op meeting thing so could I speak to him about ensuring I get someone senior to do the spinal? Or I sould just insist on the day?

Gillyan - I know what you mean by this: "I feel I am giving up on my only chance of a better birth by having the section and I honestly just don't see the section as an easy option."

That is exactly how I feel.

It sounds like you have come to a decision that feels right to you. I wish you lots of luck and hope it works out

Yes didn't want to have a general but starting to think about all of this a bit more clearly now and the risk of furthe rdamage is what MOST terrifes me. So at the end of the day a GA wouldn't be the end of the world but a colostomy bag would, for me.

I totally agree about turning whatever happens into a positive experience though