what should I ask obstetrician re: birth options after 3rd Deg Tear?

[titferbrains]

Seeing obstetrician tmw.

Saw "perineal MW" who was no fucking help at all. She just said there was increased risk of tearing (thanks, no shit sherlock) and that I had to make my own decision about what sort of birth I wanted.

I am v scared of having a c-section, don't like the idea of being cut open or recovery. Natural labour may be painful but at least baby is supposed to come out of that hole!

I was induced due to cholestasis so on top of this decision am anxiously waiting to see if chol. comes back again, from about 30 wks plus.

I am only 26 or 27 wks atm.

I just feel that docs are too quick to do c-secs and that I want to give my body the chance to do it's job.

Recovery from tear did take a very long time, it was a year before sex was comfortable again, tho to be fair we didn't try very often because I was anxious about it.
But not actually that painful at the time, just quite uncomfortable. Continence is not perfect but that's fairly normal after a baby I think, and I have no ongoing concerns about peeing and pooing.

The concern after a 3rd degree tear is the increased chance of faecal and/or urinary incontinence later on in life should you go on to have a further VB, which is why they generally offer ELCS.

I had a 3a tear with DD, and would probably veer towards a VB (probably at home as I had wanted with DD but ended up with induction and cascade of intervention resulting in the tear) - to me, an ELCS would simply be surgery now to prevent surgery later, and there are 20 odd years of improvements to techniques to be made between now and when I'd probably need anything mending. Besides, pregnancy knackers your pelvic floor anyway, so even an ELCS may not stop the damage.

No questions for you to ask your obs, but I will be watching for advice from those who have been through it - something to consider if/when DC2 comes along!

Hi
I had a 3rd degree 4 weeks ago and I asked a few of the .midwife about Next Time. They said cs was not nec and that NICE guidelines currently specifically say not to do an elective episiotomy. I am keen to have as natural no. 2 as poss so was encouraged that this might be possible. Of course every situation is different, and I certainly wouldn't turn down help if I felt I needed it so I reckon you have options and need to decide what you'd like to at least aim for (I plan to aim for natural but allow for things to change during labour)

Hi
I had a 3rd degree 4 weeks ago and I asked a few of the .midwife about Next Time. They said cs was not nec and that NICE guidelines currently specifically say not to do an elective episiotomy. I am keen to have as natural no. 2 as poss so was encouraged that this might be possible. Of course every situation is different, and I certainly wouldn't turn down help if I felt I needed it so I reckon you have options and need to decide what you'd like to at least aim for (I plan to aim for natural but allow for things to change during labour)

Am happy to keep options open but just want to be ready with some evidence/sensible questions if they push me towards a C-section.

Am not sure what are most "valid" reasons for having c-sec. My tear was 3c btw.

Plenty of time before the birth so should I ask them for more info on ladies at the hosp who have had Vag births after tears and how many had another 3rd deg?

I had a 3rd degree tear with my first (caused in no small part by being stuck on my back in hospital and forced to push before I was ready I'm quite sure). 2nd birth was at home on all fours and pushing when I had the urge - only had a graze and a barely-worth-mentioning first degree labial tear. The risk of another 3rd degree tear is pretty small (research here: www.ncbi.nlm.nih.gov/pubmed/15802413) and you reduce the risk further if you can avoid instrumental delivery and birth in a position such as all fours which really opens up the pelvis. Good luck!

had had an epidural so this is prob part of reason I tore, I wasn't really responding to any feelings, and was on back etc. Am quite bitter about how rubbish all that bit was really. Will look at research, thanks.

If it was me, I'd think carefully about the implications to continence that another VB would pose. Not just the short term implications but how another VB could affect continence in years to come, particularly after menopause, when hormones change and the muscles weaken and thin. Your vagina and perineum have already experienced a significant trauma and have already been repaired once and any further repairs are likely to be less successful.

Thanks cardamom - but my understanding is that the damage that can come up post-menopause is done anyway when you go thru natural childbirth the first time and that subsequent births don't do much further damage (unless you had a horrific tear, I guess). Corrrect me if I'm wrong but did some reading about this earlier in my pg so I could be remembering wrong.

Very frustrating. Why are people given such a range of advice for these things. Some pple on other threads were not even offered c-sec after their tears!!

Am very confused about my perineal mw's advice. she said no need to re-scan at this point because I'm pregnant, and they already know what they need to about my tear. Why did I only speak to a person I'd never met before instead speaking to the person who scanned me?? I guess I need to ask this at apptmt tmw and ask them to explain damage again. AFAIK there was damage to internal and external sphincter. MW said that obs/consultant will prob recommend a c-sec.

My instinct is that it was a medicalised birth first time round and that's why I tore and if it's not medicalised this time then I have a good chance of not tearing. But I don't think I have enough understanding of the damage that the tear did.

I think there is a 17 to 25% risk of faecal incontinence after a VB following a 3rd degree tear. The risks are higher if you had even transitiory continence problems and/or damage to the internal sphinctor.

I don't think there's much they can do surgically for this type of incontinence.

I had a ELCS for this reason a few weeks ago and was pretty much back to normal within a fortnight

did not really have continence problems except occasionally needing to rush to wee at night but not re: pooing. Is that what you mean by transitory? Have never had a problem with pooing. Perhaps that is why I feel it would be ok to go ahead with VB?

Push me, if you know about internal sphinter damage, what questions should I ask about the damage I've had and related risks?

I think I'd still try to go for ELCS - even if most of the damage is already done, you don't want any extra trauma to the area. The scar tissue you have won't stretch as easily as intact muscle/skin and any further repairs won't be as good. In my case (rectocele, cystocele, detached pelvic floor, slight uterine prolapse) there is no option other than ELCS. Well of course there is, but I'm not signing up for double incontinence thank you very much. Can't comment on sphincter damage - but my surgeon said that tearing to the anal sphincter is hard to repair well. Have you had an endoanal ultrasound or an anal manomentry to assess the damage and how well the muscles round the sphincter are working? Did you see a specialist obs/gynae physio after your last birth? Might be worth asking for a referral to one after this one (no matter whether you decide on VB or ELCS). Sorry you are facing this dilemma. It's awful - you only want to do what is for the best, but it's so hard to disentangle everything to know what would be right for you in your case. Good luck. x

Oh - and don't be fobbed off by the argument that CS has a longer and more painful period of recovery. Not necessarily, and especially if you are ELCS. I am sure your recovery from the VB was not a piece of cake - VB can take a long time to recover from.

agree with cardamom - had 3rd deg tear first time, elcs (for breech) last time. recovery SO much easier after section. was a piece of cake compared to the tear.

I have nothing to compare to re: recovery from VB! - Just remember tiredness, sweats etc. The stitches were uncomfortable rather than really sore.

STILL struggle to see how being cut open and having major surgery is better than the possibility of a tear. From what I've read, most people who have VB after major tears seem to have minor 2nd deg tears at worst.

Grr I just cannot get my head round this. I can only see reasons to avoid C-sec. I mentioned my horror of c-secs to MW and she said oh I'm glad you've done some research, some women seem to think that they have zips in their tummies

I just feel that c-secs are done/chosen without enough understanding of what the surgery means. Also, I am not sure if I am done having babies and don't want a scar on my uterus to endanger other births.

Just had a read of this and am feeling slightly ill:

http://www.midwifery.org.uk/index.php?option=com_content&view=article&id=186:risks-of-caesarean-sections&catid=91:hidden-archives&Itemid=110 here

I am 16 times more likely to DIE if I have a c-section vs if I have VB.

link

I had a VB with induction and delivered naturally but got 3o tear after dd face 1st and back to back, had immediate surgery with retained placenta, was stitched. 10 days later back in as theyd left a load of placenta in, had another d&c to remove, where they removed all of my healed stitches and then restitched, back to square 1 total utter nightmare. Useless MW's and disinterested Consultants.
My friend had a VB , induced, epidural, forceps = bad 3o tear, near 4o, was fecally incontinent for a short time. she will not now have any more kids.

next with my dd I chose an ELCS, they said I could no probs, was easy and the team were fab. sore afterwards, and weird being helpless for the 1st day, but quick recovery - I was nearly normal after 1 week. Far, far better than the dreadful traumatic VB.

dying from c-section is still v v v v v rare, but you have to make your mind up, sounds like you really want to do a Vb again - go for it.

for me it was ELCS a bit of surgery now = better than a risky VB potential further ops to correct mistakes...esp, anal surgery
I can feel my scar now, but still have no understanding how it affected my bum.

whipme, did they offer to do (emergency) c-sec when you were labouring with baby in such a poor position? In those partic circumstances I would have been very afraid of the pain and of tearing precisely because of baby's position and so would have been accepting of c-sec. what did yr midwife say? did you labour thru all that with no epidural? From what I've heard labour like that is absolute agony.

Coming to this a bit late. I had a third degree tear with my first (forceps) delivery, and was told by the MW that there was no reason not to go for a VB this time. But I ended up with a consultant appointment early on for other reasons, and in discussion was offered an ELCS. The reason was less to do with the simple fact of having had a third degree tear, which seemed no reason not to go for a VB, but the fact that I still had some continence issues. A tear that healed fine would not be a problem, but one that left residual incontinence (back passage) would point to an ELCS. It was all to do with how well I had, or not, recovered. At the end of the day, nobody knows what might happen with either kind of birth - I COULD be one of those women who has an easier second birth, no major damage, and no worsening of continence issues. I COULD find that ELCS recovery in short and long term is more difficult than a VB would have been. To the OP, get as much information as you can, and see what seems most convincing. For me, the decision was made slightly easier by the knowledge that, as an older mum this time around, the impact on subsequent pregnancies is probably not one that I need to worry about!

Well finally got some clarification today.

It turns out that my tear, a 3c, has left both internal and external damage. This means 2 layers of muscles are affected. Basically, the tear has not healed well, despite having been operated on by an expert surgeon.

Another VB will put some strain on the damaged area, for sure.

My notes indicate that a C-section is advised and I am going to have a mtg with another perineal consultant to get more info about the damage and possibly have another scan if they think it will be helpful.

I will then see another consultant at 34 weeks to try and make a firm decision about my birth option.

I am really relieved to have some concrete evidence of why I should or should not go for a c-sec. Will post again once I have a decision and any further info.

Hi there, just catching the end of this thread but I wanted to add that I've recently had a VB after a previous 3b tear and episiotomy caused by forceps delivery during my first birth. I had no tears this time. I did have a tiny 1cm episiotomy because I have an unusually short perineum apparently!

During my pregnancy I saw two consultants. One of whom said that symptoms during pregnancy are a very useful indicator of whether a c section may be advisable. He said if I had any incontinence issues at all during pregnancy that a cs would be worth considering, otherwise VB. As it happens all was ok and I had a trouble free VB.

However as I understand it a 3b means only the external muscle is affected...

Thanks very much for posting crazycat. I am hoping to get some clarification about why the c-sec has been advised on the notes, and to discuss what sort of further damage a VB might do to the existing defects. I really had not understood that the defects were still but v helpful lady today explained that the vaginal birth and labour would put those damaged areas under strain and I totally understand now that this could have more serious consequences than putting scar-tissue under strain, because the defects could seriously worsen and affect my continence, when I have had had no symptoms to speak of before now. I had previously thought that because I'd had no symptoms, I had healed well and that seemed a good reason to go ahead with a VB. The truth is I was just lucky!

titferbrains - I had gas and air and pethidene, never wanted an epidural, then when I asked for one at a really tough point they jollied me along and reminded me I hadnt wanted one
then I needed a fecking spinal anyway for the retained placenta
It was bad, but my 1st and nothing to compare it to.
After, DH told me they had been ready to leap in with forceps so probably wouldve ended up with an emergency section if theyd done that.
All stemmed from being induced at 40+11, was starting labour anyway that day, but they insisted I go in and be induced. Didnt realise I couldve argued.