4th Degree Tear - Just don't know what to do this time.

[redpickle]

When I had my first I has a 4th Degree tear, which has healed well (but cycling is a bit uncomfortable). I'm now expecting my 2nd and I've been told I can make the choice between vaginal and elective section. None of the consultants want to give me their opinion and all say 4th degree tears are quite rare that there's not much data. All they do is give me the worst case for both, which just makes me frightened. The midwifes all say labour naturally but its not them who risks double incontinence at 31yrs old.

Terrified of a section because of risks to baby, scar, recovery etc. Terrified of vaginal birth because of fear of tearing again and exisiting scar tissue being unable to re-stich. Keep swinging between the two and just dont know what to do. Does anyone have any experience of this?

Have only had an elective section due to a breech baby but it was really good,very calm and no breastfeeding issues. I was terrified of having a section beforehand and signing the consent form does highlight all that can go wrong but surgeons do this surgery 3-4 times a day, 5 days a week. If you do decide to go for a planned cs you can arrnage all your support beforehand and have lot's of help for after - you'll need it!!! but if you take it really easy you will recover well. Good luck and I'm sure you'll make the right decision for you.

I had exactly the same dilemma as you but with a third degree rather than fourth degree tear.

How far along are you? I was pretty sure early in my pregnancy that I would have a cs, but as my EDD due nearer I felt that I really wanted a vaginal birth - mainly because I was worried about coping with a cs and a very active three year old.

I had a totally natural birth but I tore exactly along the original tear - luckily not too badly, borderline second/third degree. I went to theatre to have it stitched as I didnt want to take any chances (had some incontinence after the first tear)

If I had a crystal ball, I wouldn't have taken that chance. I got away with it, but I think it could have been much worse.

It's a very difficult one, I think do listen to your instincts, it's important, but I wouldn't blithely beleive everything will be okay.

Has your hospital got a third degree clinic? Can you be referred to a colo rectal dept that could assess how well your tear has healed? THat might be very useful information.

Really good luck, I found the run up to birth this time very stressful

You obviously aren't blithely believing
everything they say btw, I just meant, keep asking questions x

I would go for a section. If they really did not think you needed it they would encourage vag birth. The fact they are giving you an option means you are a worthy case. Of course, you wil get loads of people advising to labour natuarlly and advise the risks of section but to me the risk of double incontience is enough of an argument for a c-section.

I had an emergency c-section with my first child and a VBAC with the second during which I sustained 4th degree tears.

My own experience is that I healed much quicker from the emergency c-section than the 4th degree tears.

The consultant that saw me after my 4th degree tear said that if I had another child I should labour naturally as "we can sew your vagina up again" but if we damage your bladder during a c-section it's very difficult to deal with.

I don't plan to have anymore children but I believe I would have a c-section for a 3rd. For me the possible risk of being left with double incontinence in my mid 30's would be worse than risks associated with a c-section.

A friend of mine who suffered 4th degree tears went private and had a doctor do tests to measure the strength of her back passage. She was told she had a lot of scar tissue and another vaginal birth could risk leaving her incontinent. Although not nice, perhaps you could investigate having someone look at you?

This is such a difficult decision and I wish you well whatever you decide.

I'm 23 weeks. Seeing another consultant at 32. Have a 2.5 year old, which is a factor when thinking about recovery. Mind you the tear left me unable to drive, lift etc anyway.

Sort of want to make the decision so I can prepare mentally for whichever. I do feel all the medical pros think I should go for a natural birth, which may be why I am feeling a little pressured to give it serious thought.

I have recently been thinking about these issues too, redpickle,even though we're not even trying for no.2 yet. I really sympathise as although I didn't have 4th degree I had 3rd degree 'B', worse than 3rd degree'A' apparently. Baby was in difficult position and I had failed ventouse followed by forceps. They spent 40 mins stitching me up and warned me about double incontinence. I seemed to have healed well although with a few minor probs more recently (DS now 18 months).

I would say if you are seriously thinking about natural you've got to try to pin down why you tore by talking to the doctors and getting them to explain your notes etc. Sorry if you've already done this but your post doesn't say. If you're not clear, ask to see them again.I'd want to know the likelihood of it happening again. I would say talk to doctors and ignore the midwives.You are talking about serious injury which the doctors are experienced in and about which the midwives frankly know nothing. The midwife at my follow-up just said oh second births are much easier, you could have a home-birth! I'm really tiny and find it hard to believe that that has nothing to do with why my son got stuck, and if that's right it could happen again.

From what I've read 4th degree is likely to have serious consequences and is difficult to repair. In other words, you've had a lucky escape it seems. Something I read said they're more likely to recommend CS if you've healed well so as to preserve the good work as it were, and I have to say that's what I'd be leaning towards, although I stress I've only done internet research and haven't seen a Dr about my situation yet. Also I've always been quite laid back about a CS and I know many don't feel that way.

Good luck!

Are there any factors that are different in this pregnancy? DS1 was enormous and back to back , and DS2 estimated to be only 9ib and was well positioned, so that had a bearing on my decision. Had he been as big as DS1 I would have gone for elcs (I know size of baby not necessarily an indicator of a tear but still).

My first tear was a 3a btw, had it been more serious I think I would have gone for an elcs.

I had a bad third degree tear with DD1 and was also told that it was unlikely to happen again when I was pregnant with DD2. However, I did have another third degree tear.

I am now pregnant with DC3 and am going to go for an ELCS this time even though I have two small children. I just don't think it is worth the risk of incontinence and when I saw a consultant this time around, was advised that it was my choice but any doctor would recommend that I went for ELCS rather than risk repairing the same scar tissue again for the third time and there was a real risk it would go to fouth degree given history.

I understand your dilema and I have spoken to lots of medical friends and all advised an ELCS, but you need to do what is right for you. I wished I had listened second time round!

Both pregnancies very straightforward. I had a very long, distressing labour in a very busy hospital. Left alone, even though husband sent home etc etc. I found out recently that baby was coming down with her head sideways and became distressed so they did a very rushed forceps with epesiotomy - result 4th degree tear (much like eastegg). She was only 7.5lb but it was her awkward position.

Have changed hospitals now and there have been some problems in getting hold of my notes (it really was a chaotic hospital first time), which has made discussions with consultants more difficult. Hopefully they will have my notes by next appointment.

I am 22 weeks and had a third degree tear last time, with minor fecal urgency afterwards, which has moreorless resolved.

The Royal College of Obstetricians advise that all women who have had a 3rd or 4th degree tear and have had any bowel symptoms, even if these are now recovered should be offered a section as there is between 17% and 25% risk of bowel incontinence following a subsequent vaginal delivery regardless of whether there is a subsequent tear.

I will be having a section.

I'm in pretty much the same position as pushmepullyou but I still have urgency now and am now booked in for a section for my second birth.

All the research I looked at suggested to me it wasn't worth the risk. If you have any symptoms now they will probably get worse when you go through the menopause as well. I decided I couldn't live with worse symptoms than now and apparently there is a very low chance of success with repair operations.

If I had had no symptoms at all I would probably have happily had a vaginal birth. Good luck in whatever you choose, it's a really difficult choice to make.

You dont mention which area you're in, redpickle, but the NHS trust I work for in London has a colorectal surgeon who can assess women who have had 3rd or 4th degree tears by doing an ultrasound of the anal sphincter to see how well it has healed (or how well it's been repaired).

If the sphincter has been repaired well and healed well, it should look a bit like a car tyre on scan and he would probably recommend that it would be safe to have a vaginal birth again, however if the repair hasn't been very good or it hasn't healed well the result will look on USS like there is a chunk missing and will very likely tear through again next birth.

I dont know if you have a colorectal surgeon who offers this service on the NHS at your hospital but Id certainly recommend this before trying for a vaginal birth, and if you cant have this done or its not available to you (even privately), Id really consider a c/section.

You sound like things have healed really well but I've seen several women end up with colostomys from having had a 4th degree tear, and albeit that they are a temporary measure to let the bowel heal, I personally wouldn't want to risk it.

Hope this helps and good luck.

Personally I'd go for an elective section.

I had a 4th degree tear, a very serious one which resulted in an immediate 4 hour operation to repair the damage and a colostomy (which I had for 2 years).

I was advised not to have more children because of the damage another pregnancy would do to my pelvic floor. I got pregnant by mistake and the colorectal surgeon was v clear in his advice that a section was required to protect my pudendal nerves.

I had a 15mth old to look after and, although not ideal, the recovery from a planned section was WAY easier than recovering from a horrendous birth/4th degree tear repair etc.

xx

redpickle I was in a similar situation but with 3rd degree. Chose vaginal birth, had a second degree tear which healed well.

You should take a look at homebirthing.org - they have info on there which is very useful for anyone planning a vaginal birth. Also check out the UK midwifery yahoo group - you can post your query there and get lots of very well-informed advice.

Best of luck, this is a very hard decision to make.