My pelvic floor is shot... would a csec be better than another vbac?

[DawnOfTheDeementedDead]

Long story short.

I had an emcs 7 years ago with the borth of my twins.

Three years ago i had a vbac, and ended up with a 3rd degree tear. DD was 10lb 2oz and back to back. After being sewn back up, it was never checked again, although i now believe i should have been seen at a clinic etc. I did get an infection in it as it was healing, but that was controlled by AB's from my GP.

DS3 is 21 months and at the beginning of my pregnancy with him i suffered from urinary incontinence, also after he was born it became much much worse and i was seen in clinic, where they told me to do pelvic floor excerises, watch what i drank and sent me away. I had a 2nd degree tear with him and he was just short of 10lbs, btw.

I'm now 23 weeks with DC5, and am struggling lots with urinary incontinence. Since almost the beginning of my pregnancy, i've had to wear a tena pad which i need to change several times a day. If i laugh, cough, sneeze or even pick DS3 up, i leak.

It's extremely embarrasing and i feel so ashamed that i just can't stop it happening.

I'm wondering, if this baby is another 10lber, if i have a vbac, will it completely ruin my pelvic floor? I keep thinking i'm going to be left completly incontinent. Would an elective csec be better in this situation?

I can't really talk to my midwife - i have GD, and see them in clinic only and usually theres a tribe of Drs and Consultants there and i really don't want to iscuss it in front of everybody

What would you do?

C-section.

And I speak as someone who had successful vaginal births following a 3rd degree tear after a 10lber and who hates the idea of a c-section!

Have you spoken to your GP about your pelvic floor?

Not recently, Soup. I just assumed that this was a normal part of pregnancy, but it's not is it? And it suddenly hit me that i might be left like this

No, i would say it's not normal.

DS1 was a 10pm 1oz ventouse delivery which left me with a 3rd degree tear and 2 hours of repair work in theatre (operating theatre, naturally, not a nice rousing musical in the West End). I did have a follow up check and all was fine.

No issues with DS2 who was 2lbs lighter... Episiotomy but I don't think there was a tear. Again, no problems after his birth or during pregnancy. DD, again under 9 lbs.... 2nd degree tear, all healed well no issues in pregnancy or after.

In your circumstances I would definitely push for a CS and then visit my GP abut sorting out any remaining problems.

I don't see why physio wouldn't sort the problem or at least improve things.

I assume you are doing your pelvic floor exercises...? :)

Ah, a subject very close to my heart.

After DC1, I had a mild prolapse of the uterus. However, I have a strong family history of monstrous prolapses and am very concerned that, like my mother and grandmother, I will end up with a much worse - quality of life affecting - prolapse after DC2.

I'm 28 weeks and have today seen a consultant at King's about the benefits of c-section as a means of preventing further pelvic floor damage. She told me:

• there is evidence that c-sections can prevent pelvic floor damage in your first pregnancy;

• however, there is no evidence that c-sections make any difference in subsequent pregnancies if you have already undergone a vaginal birth. In my situation, the chances of a c-section preventing further damage are minimal, assuming a normal vaginal birth. I apparently have weak collagen, which has already been buggered by the delivery of DC1 and is under constant strain during this pregnancy. My prolapse getting worse is probably inevitable, regardless of how I deliver DC2;

• that said, if my next delivery was particularly bad - huge baby, forceps, etc - it would put the pelvic floor under particular strain and having a c-section would help me to avoid this additional risk.

So the benefits of c-section aren't as obvious as I had thought before, and are to be weighed against:

• the usual risks of c-section vs vaginal delivery: longer recovery, thrombosis, injury to other organs (principally bladder) during the surgery etc etc. Also bear in mind the usual benefits - no risk of tearing, etc; but

• specifically also the fact that internal scars formed after c-sections can make subsequent surgery for pelvic floor damage more complicated - ie get in the way. The consultant I saw also does urogynocolgy and does pelvic repair operations, and said that this risk depended on the amount of scar tissue. It is worse with each surgery - and she thought the risks/complications in my case were small because I will probably only have the one c-section. But scarring can vary massively, person to person.

It is a pretty fine balance. I am going to elect to have the c-section because I can't bear the idea of not doing everything I can to avoid a more serious prolapse, even if that doesn't work out. But it is my personal nightmare and I am rather biased...

beebread - my urogynae/ob told me that whilst most of the damage is caused in the first delivery, even a very straightforward normal delivery can worsen things (incontinence) by about 40% so not sure it can be right that there is no evidence that a CS for a 2nd delivery makes any difference. To me, that just doesn't make any sense anyway.

re. CS making it more difficult in repair ops, this is not a risk that has ever been mentioned to me at all by consultants, maybe it depends on the type and degree of prolapse?

pelvic floor exercises can and do help but it sounds to me like the degree of symptoms you have mean that it is not going to cure things. my pelvic floor strength is not too bad at all but I still can't sneeze, cough or lift heavy things without wetting myself.

it's not great that you feel you can't talk to your midwife about it because of everyone being in and out of the room. can you go in and say you would like to discuss something in private and tell her then? then ask her to refer you to a urogynae consultant. if she won't or you find it too difficult then ask your GP to.

You need to speak to your midwife or GP about a referral to a women's health physio. And you NEED to speak to someone about this, it's not normal to be incontinent.

hugs xx

EachPeach I know what you mean: the idea that vaginal delivery won't make things worse seems counterintuitive to me.

But I've been told this by one registrar and two consultants (one purely OB, the other with a urogynaecology speciality) both of whom are happy for me to elect for the c-section so I don't think it's an agenda driven piece of advice (which was my initial concern).

I think the truth is that no one really knows for sure.

I was told that too BeeBread by the obstetrician I saw - that CS in subsequent pregnancy would not protect the pelvic floor. I had bad incontinence after nightmare birth with DD (first pregnancy). I've just had my DS 6 weeks ago. Initially I wanted a CS but was told no. I had a natural VB this time round and it went so much better. The incontinence is still there but it's no worse than after DD. I'm really glad I had the VB in the end and not the CS.

I've been referred to physio, but TBH I found it really horrible - internal exam, and made to cough whilst she watch me urinate on the table , only to be told basically do more pelvic floor exercises - which I have been doing anyway. I don't think i'm going to go back to the physio. I've bought one of those electronic pelvic floor stimulator things and am just going to work on it on my own.

Hope it goes well for you this time.

Sorry - only just getting back to this - DD has been in hospital.

I think i am going to have to speak to my midwife, aren't i?

It's just so isn't it?

RCOG recommends people with 3rd fourth degree tears consider csection for subsequent birth - here is the link www.rcog.org.uk/womens-health/clinical-guidance/third-or-fourth-degree-tear-during-childbirth

Sorry - meant to say that is if you have symptoms like OP, otherwise VB is OK

Ushy it says no such thing.

It says:
Can I have a vaginal birth in the future?

This depends on a number of factors. Your obstetrician will discuss these with you at your follow-up appointment or early in your next pregnancy. If you continue to experience symptoms from the third- or fourth-degree tear, you may want to consider a caesarean delivery.

If your tear has healed completely and you do not have any symptoms, then you should be able to have a vaginal birth.

Totally different to what you are suggesting. They suggest the choice is up to the patient.

quietlyafraid - don't understand what you mean - I've said the same as you haven't I? e.g. consider c/s if you have symptoms otherwise VB is ok. Perhaps you didn't see the correction I did after the first post.

Are you saying incontinence is not normal after VB ?! .
I had pretty bad stress incontinence in all my pregnancies (right from the beginning BTW), but it goes nearly entirely away when I am not pregnant.
How has it been in between? I am no expert in the field, but I plan on
delivering naturally again and then repair what needs repairing after I am done
having children. I had one episiomy (I think they equal this to a second degree tear), so I can't speak to the added complication from this.

glimmer Incontinence is not normal but it is very common. Pregnancy can cause it but it is commoner with vaginal birth. I think it is about 10% from pregnancy and 25% from vaginal birth - I think it is in the new NICE guidelines - I have done that from memory so someone may correct me.

I've been to see the consultant in this pregnancy re my prolapse. Its likely it wont get any worse with the second delivery, its the first one thats the problem. There is a possibility it will, but tbh it needs fixing after pregnancy anyway.
I'm trying for a VB this time then seeing gynae dept after for ragged bits fixing :)

I would definitely have a c-section.