Severe tear in first birth, what to do next time round??

[TheGrandOldDuke]

I had a bad tear first time round and was told in follow up I could have an elec c-sec next time if I wanted.
Neither option appeals. The incontinence I suffered after the first time, if it were to happen again and be permanent would just be hideous. But then a c-sec is major surgery not without risks either.
Anyone know any stats on bad tear first time and what happens with subsequent births?
Anyone had this problem before and what did you do??
Thanks!

I'm not sure but I did look into it as I had a third degree with my first.

From my reading, the chances of tearing again were low (but not lower) however you need to consider why you tore last time. For me it was DS being pushed out in one go and he had his hand up plus I stood up. So no chance to slow things down and protect the area!

Second time around, I tore but a second degree. It was healed in a week and I've been fine. DD decided to put her arm up too, hence the tear but the MW was ready and guided me when pushing so I slowed down (I panicked with DS).

So have a read around and see how you feel. The chances of a bad tear again are low anyway and there's no evidence that an episiotomy will help (I turned one down). Labours are supposed to be easier next time around and you might have a better chance of getting into a good position etc etc to help things.

Also being pregnant will impact on your pelvic floor too. I think I found something which implied that long term, woman who've had a CS vs VB have no real difference overall wrt to continence (as it is rare to tear that badly).

I had a 4th degree tear with DC1, I had the same decision to make with DC2.
I opted for for CS as couldn't take the risk of incontinence, for me that would be hell.
The consultant would have supported me either way, she said roughly 50% of women with 3rd degree opt for CS and is much higher for 4th degree.
My MW said if I was symptom free from first tear attempt it again, otherwise go for CS.

I had 4th degree tear first time round. I did mostly recover but it took over a year and things never went completely back to 'normal'. I was advised to go for a c section on that basis, and would have been advised otherwise if I had recOvered fine.
Fwiw an elective section was not mch fun, very sore especially for the first few days, but not nearly as bad as recovery from the tear. Also, having some certainty about the process worked wonders on my state of mind towards the end!
Hope you work things out, I don't think there's a right recommendation, just what's right for you

I had a third degree with DS1, which thankfully healed fine. I was very nervous when I was pregnant with DS2 - my midwife referred me to a consultant, and he took me through my notes from my first delivery.

We then planned a vaginal delivery with DS2, but with a planned cut, in the opposite place from the tear.

In my case, it worked like clockwork. Straightforward labour, an epidural (just because I decided I wanted one) and the planned cut.

My friend who was with me (I have a squeamish DH!), said she saw a drop of blood on the old scar, the second before the cut (she is a nurse, so I let her look ), so I guess the consultant was right.

It was a far better experience than the first.

I saw the head of doctors at my hospital after my 4th degree tear and was given no advice on whether it is more or less likely. I even asked about the effects of your hormones on stretching a compromised pelvic floor and the additonal weight for 9 months but had no definitive answer. I had my tear besides being cut so was a bit of a mess down there.

My tear was in March 2011 and am still awaiting the specialist physio, though I don't have continence problems, just that everything feels a bit looser and have had one or two v minor accidents whilst having a coughing fit or if I leave the urge to go too long.

Personally I'm not sure I could do a pregnancy again, so am really interested to hear the opinons too.

On review of my notes was told my active labour was only 6-7 hours and I'm not sure I'd want to get to hospital to have some junior dr make me push. The though makes freak out a little and the resounding memory I have is " Thank god I'm not dead".

If I ever change my mind I'd be opting for an elective c section- I'd rather have a huge scar than be incontinent.

What severity of tear did you have op? 3a, 3b, 3c, 4th?
I had a 3a first time and my surgeon who I have seen a dozen times has always maintained that women who have had a 3a tear could birth vaginally again with a relatively low risk of severe tearing again. But moving from 3b - 4th the risk of damage increases quite dramatically.

My first labour was a horrible horrible experience for a whole host of reasons and I swore I would never do it again. But I reconsidered when my GP said I could have an ECS. The ECS was a wonderful experience for me. I could enjoy the pregnancy without worrying about what was coming, and although I was sore after the operation, I healed much quicker and was mentally in a place 1000x better. I'm not saying ECS is what you should chose, just that it can be the right choice in some circumstances and can be a good experience. When I worried about my decision, my mum said to me "what's best for you IS best for baby" and she was so right - with me in a happy relaxed place, DS2 is the world's most laid back baby!!

I had a 3c tear, as well as being cut. My baby was quite big, over 9 and a half pounds, with a 2cm bigger than average head. Whilst being quite tall I am quite slight built. I hear the midwife whisper to the Dr when she was called in as I'd been pushing for 2 hours and nothing happening, that "it's quite a big baby" . Did nothing to restore my confidence!
DS was pulled out with Keillands forceps (if I'd been as informed as I am now I would have refused), I was cut and then ripped pretty much all the way through as well.
Being back on the ward after and having no control over my bowel was one of the worst experiences of my life. Having to ask the midwife to wipe my bottom because I had no idea what had happened down there was mortifying. Dealing with that plus my baby having to have an operation was too much and I suffered with PND. I don't really remember much of the first 8 months. Physically I attended the incontinence clinic for the year after, and now things are better, but not great. Sex was a no-no for about a year too. It was just agony. Basically it was a long journey and it's the risk of it being an even longer one next time round if I do it naturally. But then there's the chance it could all be fine.

Men get off sooooo lightly!!!!!

Thanks knittingmama thats useful to know. I'm just scared of surgery too!! I'm a big wuss.

I had a 3a tear and forceps first yone, haven't even considered a CS this time and am planning a homebirth in water. Supervisor of MWs said that previous tears don't make it any more likely that you'll tear again, it's pot luck. I've been lucky having no continence issues though, either post DD or even up to now (29w with DC2).

In your shoes though, I'd be opting for ELCS without question - if I'd had even a hint of a continence issue, never mind need surgery, I'd not be planning anything else!

I had a 3rd degree tear in 2009, and I'm 26w with baby 2.

I too hadn't a scooby what to do this time. Both options seemed awful, and I felt like I was stuck between a rock and a hard place.

I did a lot of reading and went over my notes from last time with a Supervisor of Midwives. The latter really being the thing which helped me come to a decision.

I felt utterly traumatised by my daughters birth. I was in horrendous pain and remember very little aside from that. It was in no way, shape or form and enjoyable experience even once she was safely born. I felt no pride for delivering her myself. Only embarrassment and regret. This compounded with the 3rd degree tear made me feel very anxious about doing it again.

Going through my notes helped me understand the precise reasons why I was so scared in a more rational way. Pinpointing these helped me figure out which things I could overcome and which things I couldn't.

She also helped me understand the risks involved re: the tear. From my understanding, you are actually only 9% more likely to suffer a tear with subsequent births. There don't seem to be any definitive stats on how likely you are to suffer another 3rd or 4th degree however. Many women go on to have a tear-free birth with subsequent babies. Most consultants seem to suggest and support a natural birth with a well healed 3rd degree.

However, the picture changes if you have continence/control/urgency issues following your tear. There is up to a 25% chance of making your current symptoms worse by having a vaginal birth, regardless of whether or not you have a tear.

This, for me, was too big of a risk. I'm planning on more children after this one, and I'm only 28. Life-affecting incontinence is not something I want to gamble with. I can cope with the urgency issues I have, although I find the fact I cannot control the passing of wind very embarrassing :( I couldn't cope if I took that gamble and lost.

I am booked for a c-section at 39 weeks.

Another thing the SoM said which helped me was to not only look at the pros and cons of natural vs section, but to look at them in terms of short and long term effects. So yes, a section screws you in the short term...but even if there are issues how many will effect you daily 2 years on.

Take your time over your decision. Bear in mind the differing advice depending on whether you are symptomatic or not. Talk it through properly with someone if you can.

Good luck.

cosmicmouse so interesting to read your account - sounds very much like mine. I have booked in to go through DS's birth in Feb, I thought if nothing else it might give me....."closure" (dreadful word!!!) I think I am veering to feel about it as you do...I think for my sanity I probably need to have a ECS. I'm not sure I can take the risk.

Waterbirth is something that I would consider if I do do it naturally - wish I'd had that option first time round. Unfortunately there's every chance I won't be given water birth option this time either. We shall see.

GrandOldDuke why would you not be 'alliwed' a waterbirth if you chose a
VB this time round? There's a belief that the water helps soften the perineum and further reduces the chance of tearing again. Apologies if I've missed something - I'm on my phone so can't recheck earlier posts once I've started typing a reply!

OP, I understand the feeling that you want to go through the birth to give 'closure'. I had a third degree tear myself with my first child and really wanted to feel I could do it 'properly' for my second. I looked in to it when I was pregnant and the statistics are pretty shocking though.

If you have had a third or fourth degree tear there is a 17-25% chance of tearin as badly again in a subsequent birth (this is proper clincal trial stuff).

Even if you don't tear again, if you have a second vaginal birth on top of a bad tear then there is a much greater risk of (permanent) incontinence after the menopause. This is highest risk where you have had continence problems after the initial tear even if these have now resolved. It is thought that up to 40% of women who suffer a third or fourth degree tear, are symptomatic afterwards, and go on to have a second vaginal birth will have post menopausal continence problems.

I had a cs for my second child. It wasn't I initially wanted, for exactly the same reasons as you. But the recovery was so so much better than with my tear. I had no continence problems and no real pain after the first 24 hours or so. My consultant said to me that the aim of pregnancy is the baby not the birth and the baby will benefit from a fit, active mother. You only get one pelvic floor and is the incontinence risk really worth it?

For me it wasn't.

Sorry about the dreadful spelling and missing words - clearly past my bed time!

Sorry, just reas your second post properly. Please, please have a cs. The risks of permanent incontinence are so high for someone in your position

pushmepullyou thank you for the stats, I hadn't realised the chances were that high. Gulp. I think I will probably go ECS, although the thought of that scares me witless too!

flisspaps there's a high chance that any future children I have will also have the 'anomaly' my DS has, so if they find that they do, I have to be on the delivery unit and no water birth for me...

I had a c section six months ago for exactly this reason. It was wonderful, my recovery was much quicker than from the vb, no problems bfing. The only down side was not driving for a few weeks but frankly I think the enforced rest and down time at home was good for me. And I say this as someone quite pathologically averse to having a c section in my first pregnancy.

I had a 3b tear with dd in 2009 when she came out fast (i was kneeling) with her hand on her ear. Like pushme I wanted to do it properly next time. CS wasn't discussed at all (but possibly because I knew I wanted a water birth) but I was told by the consultant that having a repeat tear was not more likely second time around.

With DS I was seen twice by the consultant during pregnancy and had a size/presentation scan at 36 weeks just to check everything was ok for water birth.

When DS didn't put in an appearance, I refused an early induction because u was still holding out for a water birth. At 40+14 I went into labour and was gutted to be told he wad too big and too overdue to risk a water birth.

Eventually he arrived at 9 lb 8, 37cm head. I needed an episiotomy and had a gr 2 tear which needed stitching by a consultant, although not in theatre fortunately. It didn't heal quite as well as last time but I think that was the quality of the embroidery thy. It was still sore at 6 weeks though; gp told me to come back in another 6 weeks if it wad still a problem by which time it was fine. I was much better with my pelvic floor exercises this time around and had no issues at all.

Would I have another vaginal birth? I don't know. I would if it was a girl and she wasn't late. For an over due boy? Not on your nelly!

Grandoldduke try talking to your midwife about what would happen in an ELCS to see if that stops you being scared. You can have your choice of music on, baby can be delivered up onto you for immediate skin to skin provided all is ok, you can bf in recovery, DP can be there, cut the cord etc. I was back on my feet in about 12 hrs. Hardest thing was not being able to lift toddler, but I got him to climb onto my lap for cuddles, and he sat on my lap to go "bump bump" down the stairs when he didn't want to walk. Again, I don't mean to push ELCS, I'm just saying there's no need to be scared witless if you think it could be a good choice for you.

Plus, I hugely hugely admire all you ladies who had the courage to have a vb after a bad first time. I was far too scared to even attempt it a second time

I also had a 3rd degree tear with forcep delivery and broke my coccyx. Very interested in responses to the OP as I am terrified of a second delivery ( its very early days though as DD isn't even 6 weeks yet and I am still very much in recovery!)

Question: what is the difference between a 3a, 3b, 3c etc tear?

en.m.wikipedia.org/wiki/Perineal_tear_classification

Reading with interest.