3rd birth with slight stress incontinence - vb or cs?

[3rdandfinal]

Hi there,

Just looking for some thoughts from anyone who might have been in a similar situation:

Currently 4months pregnant with 3rd baby (to be our last).

First birth was a 4-day latent stage, followed by ARM at 2cm dilated,12 hours est. labour (back to back), epidural just before transition (so numb while pushing), and ventouse assisted delivery after 1.5hrs pushing.

No continence issues after this birth.

Second birth: induction with a 10-hour labour on the drip. Epidural at about 6cm, which had worn off quite a lot by the pushing stage, so was able to feel and direct a 45min unassisted pushing stage.

After this birth, which I considered to be far less physically traumatic than the first, I was left with significant stress incontinence. With pelvic floor physio, this improved greatly by 1year after the birth.

However, I still wouldn't be able to do anything 'high impact' without slight leaking (ie I'd wear a panty liner if we were going to a wedding or something wear there'd be dancing, swapped jogging for walking, quit tennis and wouldn't even consider bouncing on a trampoline). Also had to be really diligent with kegals to maintain this level.

Now pregnant with third. Consultant has said a ligament close to the urethra isn't working properly, but other than that everything looks okay. He'll support either a vb or cs, but is leaning toward vb with the opinion that any worsening of stress incontinence can be addressed separately and subsequently with a TVT-type operation.

My instinct is that the damage was really done with the first birth, even though symptoms only manifested after the second. Regardless of when the damage occured, I'm really concerned that a third vb would do more permanent damage, and my priority is to reduce the chance of this. Thinking longer term, I'd like to be able to manage without any operation like the TVT until after menopause. Because of this, I'm leaning toward a cs.

I don't want to go ahead and go for the cs option lightly, as I'm really quite frightened of the surgery/risks and recovery would be difficult with a busy family to manage, but at the same time, whilst my continence is just managable now, any worsening would have a significant negative impact on my quality of life.

Has anyone else been in this situation, or have any advice?

Thanks for your thoughts

I'm interested in the responses you get as am in a similar position (2nd baby, posterior vaginal wall prolapse but no incontinence).
I haven't seen the consultant yet but my intention is to go for a zero intervention vaginal birth and switch to a c-section if any intervention is needed. As far as I can tell having a drip, epidural, lying flat on my back or having an assisted delivery would all potentially contribute to a worse outcome. So as long as the consultant is in favour, I'm planning a home birth. I will also be requesting to have my 6 week postnatal check with the consultant rather than the GP (who didn't even examine me last time and this prolapse wasn't picked up till my current pregnancy). Hopefully that will be possible and I can get a quick referral if I end up needing a repair job.
My main reason for not wanting a CS is that it would mean a stay in hospital away from my daughter and recovery would be harder and longer.
That's probably not helpful for you... but its nice to know other people are going through similar issues and I'm not alone

Thanks for your response thing1 - nice to know I'm not alone too!

I think we're thinking the same thing; that a vb with interventions would most probably worsen the situation for us, but an intervention-free vb would only possibly worsen things, and might not make any difference. However, my experience is with 2 births at nearly 42 weeks, both with varying degrees of induction, so I'm not confident that it'd be intervention-free for me. Part of me wants to go for a waterbirth at the mlu, for the same reasons you outlined. Part of me wants to play it super safe with my one and only pelvic floor, and opt for the cs. And part of me doesn't want to undergo major surgery, with all its implications for my health and family life, unless it's necessary.

Such a tricky one!

I am interested too... I had a similar birth to yours for my first with Kiellands forceps delivery, having stress incontinence since 15 weeks preg, can't cough or sneeze without loss even if I go v regularly, there is some vaginal prolapse too.... don't want to be induced again this time, otherwise looking for no intervention vb if possible...

It's so tricky isn't it. This will be my last (planned) baby so I have thought about the CS as it's not like I'm planning any more - so I'm not worried about being higher risk in future pregnancies. But unlike you I had a non-induced 8 hour home water birth last time, with a 7lb baby, so I'm assuming I've got a good chance of it being quite straightforward this time. I really want to know how I ended up with this damage! I don't fit any of the typical patterns (e.g ages pushing or forceps). I think maybe I just pushed too vigorously - I felt like I'd been kicked in the arse by a mule the next day my bum was so sore.
I do think it's worth making your pelvic floor quite high priority, as you'll have to live with it for the rest of your life! For me, doing a poo normally is quite difficult. If I need to bear down at all to poo, my rectum prolapses through the muscle in to the vagina - I have to put counter pressure on my perineum to hold it back... I really don't want to be doing that for the rest of my life. The physio says pelvic floor exercises may help but aren't as useful for this as they are for incontinence issues. Hopefully I can have a stitch or a bit of mesh after the birth to strengthen it up again.
I guess we need to weigh up risks of surgery (CS) vs risk of further damage, and also how good repair ops are if you do have further damage. Also some evidence says pelvic floor issues are as much to do with the weight of pregnancy as the mode of delivery. I don't know enough about it to make a decision at the moment. Could you ask to speak to your consultant again?
Best wishes with everything.

Oh I am kegeling a ridiculous amount all day every day, the weight of the prolapse reminds me... terrible dragging down there if I walk etc. I probably want three too, that puts me off... I want the experience you had last time, but incontinence is so degrading, I am paranoid of smelling of wee half the time! I don't even notice a lot of the low level loss so have to go to the loo almost constantly to keep on top of the hygiene. Were your babies big?

Working - mine were both 8 1/2 pounds. Incontinence is a nightmare, I really feel for you. When I had it badly I also had PND, and I think the depression was related to how I was feeling about my situation. I am 4m now and can feel that everything's more lax, ie I can feel that dragging heaviness if I stand for a while, and feel the strain if I pick up a heavy bag of shopping, but no incontinence as yet (although there would be if I weren't managing my lifestyle to avoid things that make me leak).

Thing1 - I think I've got the most I can out of the consultant... he was quite frank and said, 'look, if you asked 10 of us, 4 would say cs, 4 would say vb, and 2 would say they didn't know... the truth is we don't know.' Like you, I wish I knew exactly what the cause was (aside from 'having a baby!)... it would inform a lot of decision making. It would be helpful to access relevant stats too, but I can't seem to find anything that's not related to forceps deliveries and/or major tears - whereas I had an episiotomy with #1 and a small tear with #2 (I think it was a small - there were about a dozen stitches). It's a great idea to request a consultant for the 6 week check. Best wishes and good luck to you too

Hi I think I can help with this question.

My first VB was very traumatic, similar to OP's but with 3 hours of pushing and 3 venteuse attempts. Nevertheless i did not experience any incontinence afterwards.
Second VB was a precipitate induced labour (1 hour from 2 cm to baby) and left me with incontinence issues similar to OP's. I was under the care of the most senior consultant at the Rosie in Cambridge who said that the damage would have been caused by the first labour/delivery and not due to a fast 2nd VB. it took me about 1 year to have acceptable bladder control again.
Eight years later we decided to have our third and last. I've had problems emptying my bladder from 16 weeks of pregnancy but not too much trouble in terms of incontinence during the pregnancy. I went back to see the same consultant to ask exactly the same question: shall I go for ELCS so that I don't make bladder problems worse. He said it wasn't worth it at all because all research in this field shows that the damage is usually done by a first traumatic VB and subsequent VBs don't make any difference. Even though I know how senior this consultant is I wasn't convinced that he wasn't just trying to avoid a CS at all costs which a lot of doctors in NHS hospitals tend to do. I was very worried and really thought I'd have the worst time with my bladder post birth. Even though I wasn't keen on the idea to have my stomach cut open I would have gone for a CS if that had been offered to me just in case another VB could damage my pelvic floor further.
Well my DS3 was born almost 3 days ago and it was a very straight forward VB. What's more, one hour after his birth I was able to control my bladder very well and haven't leaked any urine since! I am managing to empty my bladder fully again and feel like i did before i got pregnant. This is in sharp contrast to all the trouble I had after baby number 2!
So I have to admit that for me the advice given by my consultant was spot on and it wouldnt have been worth doing a CS just for the bladder issue.
I hope this helps somewhat!

Thanks Vanilla, that's really interesting and encouraging in terms of vb. Similar situation by the sounds of it... I've had a 5 year gap between 2nd and 3rd. It really feels like the damage was done with the first birth - ventouse, episiotomy and also manual removal of the placenta which was physically quite full on. I think maybe I'm going to have to keep an open mind, stay fit and healthy for either evenuality, try not to feel anxious with the uncertainty around the delivery and have a more in-depth chat with consultant/s later in the pregnancy. Great to hear similar stories, thank you :)

Or find someone with a crystal ball and ask them!

I had a difficult birth with DS (2.5), forceps, manual removal and a lot of internal tears, resulting in an anterior and posterior prolapse. I was worried about another vb with DD who is now 12 weeks and looked into elcs. However, I had a very straightfoward birth with her and 12 weeks post delivery my prolapse is certainly no worse and possibly slightly improved.

Good to know Edwin bear. I guess I'll stick to plan a for the time being then.

I don't have any continence issues but there is definitely an uncomfy posterior vaginal wall prolapse since having my second (although the gp said it was 'mild'). I would not have considered a section unless there was a really strong indication and it is definitely no worse since giving birth to dc3 two years ago. Probably helped that he was slightly smaller than dc2 though!

I would agree with the consultant that in most cases the damage has already been done and it is usually better to go for a vaginal birth and a repair at a later stage. If baby is much bigger or mum has previously had more than one instrumental delivery then this might not be the case though. (I am a midwife btw)

Hmm, so that's quite a few cases of a 3rd birth not making things worse... am starting to reconsider - I realise I'd been mentally preparing for a cs.

One thing that was also putting me off a vb, along with risk of further permanent damage, was having to put up with another year of incontinence straight after the birth, but from your stories it seems this might not necessarily happen.

thanks everyone for sharing your experiences.

maxbear - thanks for your personal and professional thoughts, much appreciated! Do you happen to know if a repair would be a more complex, less routine operation than an elcs, or are they pretty straightforward? I think in my case if I had a straightforward 3rd birth I would probably only need a TVT (if anything... physio might do the trick)...

I am no gynae expert (haven't worked there since I did my training 16years ago! I would think that a caesarean section is a much more major op with more potential for losing a lot of blood, as a repair would not involve a large scar/cut as a cs would. Usually stitching or tape but as I say not a gynae expert. The other thing is (depressingly) that pregnancy will often worsen symptoms of stress incontinence even in women who have a section. Fingers crossed you will have a spontaneous labour of a smaller baby. Keep active towards the end to optimise the babys position and hopefully you won't go overdue.

Thanks maxbear. Fingers crossed indeed.

I feel a little bit less anxious having just talked around things on here, which can only help - have been worrying quite obsessively about it all.

Symptoms are getting worse this last week, but hopefully it's due to relaxing hormones / increasing weight on pelvic floor, and not lasting damage.