How to minimise chances of a repeat tear? And a rant, because I'm enraged.

[Hopefully]

I'm 37+3 today, and just seen my consultant to be booked in for CS due to a 3rd degree tear and PPH with DS. Unfortunately, because my blardy MW didn't feel the need to book me in with the consultant early enough, there are no slots left for electives until my due date.

I obviously got cross with it all and complained, but basically the slots aren't there, so there's not a lot they could do apart from apologise (not that they did apologise, but anyway). I'm so furious about this, as I was totally traumatised by DS's birth and the aftercare, and part of the benefit of the CS, for me, was that it was meant to be a much less stressful experience.

Hopefully I won't go into labour before the CS (DS was late), but with it being a week later, there is a bit more of a chance than previously.

Because DS's labour was pretty quick, the chances are that this one could be similar, and the consultant has advised that unless I am in very early labour when i come into hospital, the balance of risk suggests that I'd be better off delivering naturally rather than risk a CS at a late stage of labour (apparently this is riskier?). DS was also massive, and while I wasn't too worried about delivering a baby naturally over a week early (i.e. before I was expecting my CS date to be), there's a chance that if it's full term that it could be as big as DS, so the risk of tearing increases again.

Anyway, I'm trying to write a birth plan in case I do have to go in and deliver naturally, and I'm wondering what I can suggest that might minimise the chances of tearing. Is there anything I can ask MWs to do while I'm in labour that might slow things down/slow down actual delivery/minimise tearing?

Alternatively, if anyone can pull a spare consultant out of their hat so I can have my CS at 39 weeks, that would be lovely.

Wow, that's shocking treatment from your hospital. I suppose mistakes happen. I do like your attitude of getting on with it and preparing for a vaginal birth though.

Do you know why your tore with DS? Did you have an instrumental delivery?

I believe the following help to avoid a tear:

• eating healthily and staying hydrated in pregnancy to help elasticity of the skin (fish oils etc).
• No directed pushing, going with your bodies urge to push and slow crowing - panting and not pushing to allow the tissues to stretch gradually around the baby's head. Midwife can direct you on this (and probably will even if you don't ask).
• Giving birth on all fours or side lying (left hand side) with someone supporting your upper leg.
• Not giving birth on your back - this is like pushing uphill and makes you much more likely to tear.
• Relaxing your jaw as your bear down in the 2nd stage as this also relaxes the pelvic floor.
• Consider perineal massage? Although mixed views on whether or not this prevents tears.

p.s. even after tearing once, your chances of tearing again are only about 5% (depending on what category of 3rd degree tear you had last time).

So there is a 95% chance that you won't tear this time.

bloody hard not to push when you have them shouting push at you tho. as i did for 2 hours, and baby wasn't in any stress at all.

Thanks for the responses everyone.

Dirge I do feel completely let down by hospital. Like you say, mistakes happen, but it does feel a bit like that the entire trauma of DS's birth is being swept under the carpet, simply because if I did go into labour, the chances are it would probably be OK, or at least no worse than last time. Apparently the fact that I refused to consider TTCing number two until my CS was guaranteed is not particularly of concern to them

Was on all fours (well, hanging over head of the bed) with DS, so can definitely manage that. I think one of the problems last time was that I asked to not be told to push unless there was a problem that necessitated getting DS out, and they went ahead and told me to push. Which meant I panicked, and pushed like buggery. DP is pretty strong willed though, so I will instruct him specifically to question why, if they encourage me to push again, and to reiterate about tear an necessity for slow birth.

Oh, and I also had a cervical tear, which I think is slightly less common. Don't know if that's relevant or not.

Am also worried about recovery/later problems - I was enormously lucky after previous tear to have brilliant surgery, and apart from a (very) slow recovery, I have had absolutely no problems ever again, even throughout this pregnancy, and I know lots of people who have major problems following repairs, need further surgery etc etc.

I have a lot of first hand experience of tearing and the subsequent problems Hopefully so I completely understand your worries.

You're both right about it being difficult not to push when you're being told to push. I get that, you're vulnerable in labour and its hard to go against any kind of direction from HCPs.

Have you considered giving birth in water? Apparently it can support the perineum and also softens the tissues making it easier to stretch.

I think the fact that your tear seems to have been caused by directed pushing and perhaps the perineum wasn't given the time to stretch fully. Did they say there was a problem with DS that meant you had to push him out fast?

Also, have you considered hiring a doula? They can be great advocates for you in labour, particularly if you are asked to push again despite what your birth plan says.

I've heard that water can help, but I'm really not much of a water baby, and the idea of a waterbirth alarms me so much that i reckon the added tension would outweigh any benefits!

There was no problem with DS whatsoever - they just told me to push, counter to my birth plan, because I was fully dilated. As it happens the urge to push was there, but instead of pushing when I felt the urge, I vaguely recall just pushing like a mad woman, which presumably didn't help things.

I did think about a doula, but TBH I'm very confident in DP as an advocate for me in labour (only reason he didn't question things like being told to push last time was lack of knowledge and assumption that they would actually abide by birth plan! We know better now). I'm also not sure I could become comfortable with someone quickly enough at this stage (3 weeks to go) to want them at my birth, and I don't think I'd necessarily want someone extra there if I do get my CS, so it would be a waste of organisation/money etc.

Urgh, I'm just so pissed off with the whole situation. Childbirth seems destined to not be easy for me, one way or another!

i think they should have cut me, becuase i was pushing and she was going back and fore against my not stretched at all perineum for about an hour. I have heard of such a thing as an unstretched perineum, one that has no give and i think thats me. I had no urge to push at all.

My dd was 6lbs, and when i gave that last almighty push she flew out, and i tore badly, everywhere. right up to the clitoris, and many grazes.

midwife didn't guide me at all, was very offish and rude.

V sorry to hear this hopefully - I was on your antenatal thread many moons ago, and i think our DSs share a birthday!

Are there any other mat hospitals in your area? I know there may not be outside of the cities. I would be pleading/demanding that they see if another unit could fit me in. Very bad.

On the not tearing front, Ina May Gaskin's book about Natural Childbirth has a big section on this. Can't remember any of the tips but remember being impressed at the time!

Hi Hopefully Sorry to hear about your situation.

I was going to suggest a waterbirth. I'm not a water baby either, but the relief of warm water is immense.

DS2 was 9lb 11oz and was born in water (with no coaching by a MW, as she only arrived as ds crowned) and all I suffered was a graze.

I believe the graze was because there was no control on my behalf when he crowned (I didn't actually realise I was crowning), and I also believe that the water supported and stretched my perenium because I also didn't experience 'the ring of fire.'

DS2 was my first vaginal birth and even though he was a whopper I really do believe that a combination of:
his positioning,
my labour positioning (all fours),
the second stage being in water,
doing what my body was telling me to do all of the way through labour and delivery,

all helped to make a quick and really quite easy delivery.

I'm also not convinced that tearing has as much to do with the baby's size as we are led to believe. I know ladies who have had extensive tearing with 6lb babies.

Maybe also read up on PPH's and find out whether they are more likely with a managed or natural 3rd stage.

Any questions just asked, I should imagine your head is whirling at the moment.

It might be worth phoning the delivery suite daily to see if any of the other people booked for CS have delivered earlier than expected, thus freeing up a space nearer 39 weeks for you?

After much outrage on my part, I have been given 'permission' to phone booking in receptionist when I'm 39 weeks (I'll be phoning every few days from 38 weeks onwards!) to see if anyone booked in for earlier slots has had an early delivery, and I can nab their space. Not quite the relaxing, scheduled birth I was hoping for, but if I can bump things up a couple of days it'll be worth it.

ILTMIMI I think they now have pools in most of the birthing rooms at our local hospital (just had a massive redevelopment, looks fab!), so perhaps I could get them to fill the pool if I do go into labour and see whether I fancy it. The worst that can happen is I get out, i suppose!

Charity there are a couple of other hospitals within 40 mins or so, but both have less good reputations than my local hospital for both birth stats and BFing rates, so apart from the rather major CS booking problem, I'd rather stick with mine. Thanks for the book recommendation - I think one of my friends has a copy, so I'll go and scribble some notes from it.

Hadn't even thought of the options to reduce the risk of PPH! I suppose it did make recovery slower, but I've been so caught up in the fear of tearing I've hardly even thought about that.

How lovely, that the best way to distract oneself from the thought of losing a couple of litres of blood is to focus on the possibility of a repeat tear from cervix to perineum. Ah, the joys of childbirth...

So sorry you're having to go through all this stress and worry right now. I hope you get a slot for your CS.
No positive tips to add but I'm so annoyed for you about the lack of thought from your community midwife. I'm starting to get really cross about the lack of care and mistakes I hear about on a regular basis!
I got so fed up with my midwife when having DD2 that I refused to see her and wiould only see a hospital MW. She'd say DD was breech still, then write the opposite on my notes. More importantly, I asked her for a referal to the perinatal MH team(I suffer from depression during pregnancy aswell as PND), she 'forgot' and I was near breakdown point when I went begging to my doctor to speed up the referal.
Next time around with DD3 I gave her the benefit of the doubt and she seemed a bit more switched on, BUT, she missed my pre-eclampsia warning signs and I ended up having seizures and very ill!
I know they are all very busy etc, but they have a duty of care to pregnant women, and some seem to letting them down.

You've got some fantastic advice from others and also have a great attitude to it all.

FWIW, it sounds like it might help if the consultant made up her/his mind about whether you needed a section. A friend of mine has a heart condition, was advised that she needed a section and booked in for 39 weeks. She went into labour at 37 weeks, went to hospital who took some convincing that although she wasn't booked in for a couple of weeks, the baby didn't know that! It was clearly on her notes that she required a section and eventually she had one.

This could mean that your birth plan is to get to hospital as soon as you get the first twinge and they'll do a 'planned emergency' section.

Have you tried contacting PALS? In my experience, they can exert additional pressure on 'systems' and do some of the legwork and stressing for you.

Good luck.

Interesting reading (selfishly) as my 2nd degree tear and blood loss are putting me off having any more children! (could also be as dc1 arrived v recently!).

how do you know where you tore? I wasn't told anything apart from I needed 'lots of stitches'. Still hurts 5 weeks later : (

birth was v natural and baby was fine (on the large side though!). Think I tore cos of directed pushing - I just didn't feel the urge, like what piratecat says - and didn't feel I was doing it properly.

Good luck OP.

You may be able to see a scar (though perhaps best not to look at it just yet, make sure it's healed).

You could ask your midwife or gp at your 6 week check. Mine had drawn a little diagram in my notes so I knew where mine was (though mine was a 4th so it was pretty hard to miss!!).

I was just going to post what RoseBud05 said - about getting a confirmed CS booked in, whenever you can get one, with an agreement that if you go into labour before your agreed date, you will come in asap and they will do a 'planned emergency section'.

That's what happened to me (my waters broke 10 days before my planned CS date).

Your consultant is being a bit unhelpful with the old 'better to give birth vaginally than risk a late stage CS' advice. He's right - but the point is, if they have agreed a CS, the advice should be to get to hospital like a shot if you think labour is starting (which of course is the opposite advice for labouring women normally, where they are told to stay at home, have a bath, etc).

If you have an unusually fast labour, things may progress too quickly, of course, but that's very unusual.

I think you've been put in a very difficult position, and your MW is at fault here for being slow to book you in. It now sounds as if they are hoping you will give birth vaginally because of an administrative cock up on their part, and that's very unfair on you, and very poor care considering your history.

By all means prepare for a VB if you want to, but I'd get a CS booked in for whatever date is available, get a meeting with the Consultant MW, or Consultant, and get them to put in your notes that if you go into labour beforehand, you will come in asap and they can do a planned EMCS.

It is possible, that was my birth plan, and it worked perfectly.

Good luck.

I had a massive PPH (3 litres +) and an extensive 2nd degree tear requiring surgery under GA. Think direct pushing could have contributed but as DD's heart rate was dropping with each contraction I just pushed as hard as I could. Anyway, I am interested to see that you have been advised to go for C-section as my consultants have advised vaginal delivery as the risk of excess bleeding during surgery is greater if you have a previous history of PPH.

My blood loss was higher because I wasn't at hospital when I delivered and I'm not keen on a C-section so happy to go with what they advise this time round (when I will definitely be in hospital).

If you don't get your planned C-section for whatever reason this might be something to keep in the back of your mind. Tearing isn't fun but neither is almost bleeding to death having only just met your new baby.

Thanks for all your responses and experiences, everyone.

notasausage I didn't know that about bleeding during surgery. I suppose that perhaps because the tear was pretty bad (although 3rd, not 4th, it was fairly consistent from my cervix down, not just at the exit, iykwim), and the PPH relatively minor (especially compared to your 3 litres!), the balance of risk for me is in favour of a CS.

I saw MW on thursday, and expressed my displeasure at what had happened. Luckily, despite it being her cock up, she was much more supportive than consultant (have not had good experiences with her thus far), and basically said what all of you have said - if the consultant agrees that I need a CS, then I am fully entitled to demand one if I go into labour. She said several times that if I feel any twinges at all, I can just go to hospital and be monitored, and if I am in labour then I can insist on my CS straight away. She also said that although consultant described my labour as fast, that unless things are much faster this time (I had my first 'proper' twinges about 6-7 hours before DS came out), there should be plenty of time to get to hospital. Especially since we live about half a mile from it, in a quiet city.

I'm still fuming about what's happened, and have registered a complaint with head of midwifery (just in case this is something that's happened before or since, so at least MW might be pulled up on it if she's being a bit slack). However, I'm trying to just focus on a positive birth, one way or another. Will keep trying for an earlier slot though. Hopefully there won't be any last minute dramas with me going into labour!

Oh, and whoamamma 5 weeks in I was still in bloody agony. i think there's a lot of expectation that if you deliver 'naturally' you should be up and about very quickly, and that's just not the case if you have PPH or tearing. I asked for precise details at my 6 weeks check (until then I pretty much just knew that I had a shitload of stitches, although I think I knew it was 3rd degree), and consultant drew me a diagram. Any medical profession with access to you and your notes should be able to talk through exactly what happened. I found talking it through with the consultant really useful, just to find out more details and be more informed for next time.

And it took me a good year before I would even contemplate more children, and then only when I was absolutely guaranteed my CS (nice to see that my wishes are being so thoroughly respected )