Post natal care questions for 4th degree tears- NOT FOR THE SQUEAMISH

[Catspersonalbanker]

Should I complain about the consultant?

Bit of background
I gave birth to DD in March 2011.
Planned homebirth was overdue by 6 days when labour started. Labour took a awhile to progress, was 3cms from 9AM to 5PM. On call midwife attended at 7PM to check me and water broke and was at 7-8 cms. Birth pool put up, got in after numerous baths using gas and air.
Labour to full dilation at home but found it increasingly hard to communicate that I wanted more pain relief. Couldn't talk and had eyes shut for most the time.

After 4 hours midwives got me out to check me, after tell me that I should have been ready to push and having me stand out of the water to try and get gravity going for about an hour.

Then meconium in the waters so a a swift transfer to hospital at full dilation in an ambulance. Though none seen in the hospital and baby not in distress at all

Transition seemed to be never ending, oh and contractions never established a set rhythym either.

Got me on the bed to examine me. In fairness the midwives tried when I was standing but no joy.
Agony being put on my back.had a catheter I must have been fully dilated for about 4 hours total and had no urge to push. Legs strapped up and being made to push with contractions that didn't seem complete.

MW were very good but I pushed for about 1.5 hrs before they go the Obstetrician in. MW were excellent.

Obstetrician another matter.
She told me I had a pyschological barrier to pushing!
Stood over me with forceps and said if I didn't push hard enough she would use them.
Had me pushing without contractions at the end.
Cut me but I still ended up with a fourth degree tear (through all muscle and mucus membranes). Had to be stiched in theatre, stitching alone was 45 minutes.
I still have a pelvic floor waekness and have been told not to lift anything heavy or do exercise that may impact on my pelvic floor like running, which I loved to do previously. Also have to have specialist physio.

From my post nantal consultant appointment it has become clear that the reason for this is that the babys head was too big (their words not mine)They are recommending that if I wanted another child the best course of action is a preventative episiotmy rather than an elective c section?

Surely this can't be right if first time round I had a preventative epi and still tore so in effect had two wounds to heal? Also I'm concerned that a second event like this could leave me incontinent

I should add , I am not bitter that I didn't have the home birth I wanted, am just really disappointed that my body ended up in such a mess and it is putting me off wanting another child.

Any ideas for a way forward.

After 4th degree tear, I was advised a section second time round. Apparently the decision was made on whether I had any remaining symptoms which I had, but nothing horrendous. Incontinence or colostomy were the biggest worry in case things went wrong again, but apparently the damage is likely to have an impact in decades when everything moves south (gulp).

And fwiw, I had both sorts of episiotomy (can't remember the names, one straight and one sideways) and still a 4th degree tear, so maybe if it happens it happens.

Pilates, Pilates, Pilates! Three years on and another baby, I'm back to running again now. Good luck!

Thank you for your comment. I have gone back to Pilates having done it for 2 years before DD.

It is the longer term damage I am concerned about too,
Sorry if thisis TMI but I have bought the booots weughts and can use the heaviest one so can' tbe that far off "normal"surely?

Sorry you had to meet such a horrid consultant. Sounds like your baby wasn't well positioned to come out easily- that would explain the irregular contractions and no urge to push.
Awfully condescending and rude for the cons to suggest it was psychcological.
Your fourth degree tear was probably caused by the forceps delivery with the episiotomy. The baby's head was not 'too big' or it wouldn't have passed through your pelvis!
There is no evidence to suggest that an elective episiotomy will prevent a further 3/4th degree, but some evidence to suggest that it contributes to it so thats a pile of bollox as well. There is a chance you won't tear at all next time, but theres no way to predict that.
An elective LSCS will remove that risk but open you up to another set of risks. You have to weigh up the risks for yourself what you are more imporatant to you and decide on that basis what to do next time. If you saw a different consultant, they may more sympathetic or have different recommendations
Personally if I was having on going problems with my pelvic floor, i'd opt for the section, but thats just me.

BadDayAtTheOrfice
I didn't have forceps in the end but tore separately to my epi cut.

My husband has abig head so that sort of make sense in a way but I hear waht you are saying. Baby was 8Lbs8oz and I'm 5'1 and size 10, V large baby + small woman+ husband with big head= big owch!

Catpersonalbanker one thing caught my eye in your account - have you thought of talking to an obstetric litigation lawyer about what happened? Initial chat is free with many practices. There may not be a case but I would certainly get your notes and compare them with NICE guidance. 4th degree tears are classed as serious maternal morbidity and can (although hopefully won't) give you down the road problems.

I certainly would question their plans for future children. You absolutely do not want to end up with incontinence - it is such a horrible outcome. Elective c/s is safe if you don't want a big family but the NICE guidance on caesareans has a good unbiased description of risks and benefits. I'd go with Baddayattheoffice on choosing c/s next time but obviously depends on how you feel about these things.

www.rcog.org.uk/womens-health/clinical-guidance/third-or-fourth-degree-tear-during-childbirth

Might be useful for you but sums up excellent post by baddayattheoffice.

As the link says, third and fourth tears can't be predicted or avoided (in fact I was supporting a midwife during a delivery yesterday where the lady sustained a 3a tear - there was no indication at all). It really does sound like your baby go into an odd position.

Thank you for all your comments.

Ushy- I don't think it was anyones fault what happened. I has 2 community midwives at home during labout and had see 3 over the previous 24 hours, plus a student. Then two midwives in teh hospital and obstetrician and no bodt said anythign about placement. Just oe of those things.

I am very lucky that it was noticed and deal with immediately. Touch wood, I only seem to have mild muscle weakness- iy could have been so much worse.

Had the letter from the continence clincin telling me that my scan showd signes of scarring probably from obstetric trauma- as if I didn't know that!

But also ran into my community midwife at Baby clininc today so I told her about hte letter. She agreed with me that I'd be better off with a c section ( and she'd be the one to refer me) . Considering that she's had 6 naturally and I told her when I was pregnant that if I went crazy in labour she could tell me to pull myself together, I think we could work something out with a level head in the future.

Still not sure about baby no2 but no loger so scared about it.

OP, it would be totally reasonable to request (and have) an elective LUSCS after a fourth degree tear. If an obstetrician refused, you could ask to be referred to someone else. 4th degree tears can have serious sequelae and should never be taken lightly.

If it helps at all - I had a 4th degree with dc1, but suffered nothing long term except maybe a bit of pelvic floor weakness.

Sounds like I was given different advice to you, as I hHad dc2 naturally (offered CS but declined after discussion with the consultant who said there was no reason to have it as I was asymptomatic). That birth was fine, although I did have an episiotomy to direct any potential tearing away from rectum. The decision for the episiotomy was made last minute when it looked like I wasn't going to stretch.

Now pg with dc3, and a bit worried about another natural birth but am going to go for it with good positioning during labour and NO hard pushing. My main worry is not what things are like down there now (pretty ok) but what things will be like in 30 years time...