Doing it again after traumatic first labour - what would or did you do?

[backinaminute]

Sorry as this has probably been done a million times before but I'm after some objective opinions.

I have a 15 month old ds and number 2 is due in December. Last time I went over due, was induced at 40+11. The pessaries kicked off the contractions but after 12 hours of those was only 3cm dilated so went on the drip (as well as having an epidural). He ended up back to back, he got stuck - was a failed ventouse and delivered by forceps in theatre. Other than being a bit squashed he was fine but I had an episiotomy and a 3rd degree tear followed by a post partum heamorrhage (1.5l).

So now pregnant again, I'd convinced myself that second labours are usually better, body knows what to do this time etc etc. my plan was that I would do everything that I could to avoid intervention as I'm a little bit convinced that it lots of small things that went wrong - a kind of chain reaction from the induction. I thought i will be as mobile as i can in labour etc etc. I've seen 2 midwives who agreed with me. Then I saw the consultant who basically said that if I was to do similar damage (tear-wise) as last time they wouldn't be able to repair me as well and I might be left feacally incontinent, possibly forever, and basically advised me that I should have an Elcs which I really wasn't expecting.

I've seen my midwife again who hasn't changed her stance and maintains that what happened last time is unlikely to happen again. She also said that maybe I should get a second opinion.

Dp and Dm think I'm completely insane for not snapping their hand off for a section but I'm just not sure. I've kind of got my head around it but I'm terrified of having to look after a baby and a 20 month old after a section (although I'm really lucky as have lots of help being offered as everyone thinks I've lost my marbles for considering a VB with these risks).

On one hand I know the risks are low and it will probably be fine but on the other I also know that if it was that consultant that had to deal with another bad tear she'd know that she wasn't doing the best repair job. (luckily I don't have any symptoms from the tear). And as much as those around me don't seem to believe that I think shitting myself for the rest of my life is a bad thing it's not something that I want to have to deal with if possible.

Sorry this is so long - I guess I'm asking if anyone has had anything similar and how did go second time? And generally after some thoughts. I don't know why I feel so guilty going for a section for the risks for me rather than the baby?

I know I don't have to make the decision yet and keep pushing it to the back of my mind but I just keep mulling it over. Thank you for reading me droning on.

you also have to think of your DP, hopefully he will love you if you do have fecul problems but....a few years down the line of helping you to deal with this problem, knowing you had a choice to avoid it....and a choice I might add that some women are fighting for.....

Forceps and large epi first time - baby back to back and nine and a half pounds.

Second time around homebirth - 11lb baby, no instruments needed nor stitches. I was ecstatic.

I had an independent midwife for second baby and she was fab. IM have the lowest rates for perineal damage according to the research.

My understanding about the advisability of vb after a 3rd degree tear all centres around whether you've had any symptoms associated with it. Any symptoms of fecal incontinence and I think there would be agreement among midwife and doc that c/s is best option.

Eliza - there are many many women with bowel problems following birth who are not divorced, friendless and suicidal. The vast majority in fact. I myself have issues following my third birth and I can promise you - I'd STILL rather have had a v/b! You are suggesting terrible worst case scenarios to OP without acknowledging that there are also terrifying worst case scenarios associated with c/s. For the op the best outcome and the preferred on would be a straightforward v/b, which actually is the outcome which is most likely if you look at the stats. What she needs is as much information as possible about the likelyhood of having another 3rd degree tear and the things that might influence that outcome.

Seriously - its not helpful this .... well I was going to say 'shroud waving' but a slightly different image came to mind involving toilet paper...

Flisspaps - Are you really saying that you would refuse an operation even if you were told there is a 20% chance of imminent death if you don't have it?

I hope you are just saying that because you don't want to accept you were being unreasonable in your risk assessment for OP.

What she needs is as much information as possible about the likelyhood of having another 3rd degree tear and the things that might influence that outcome

Where do you think she can get that information from? Consultant midwife (if there is one)/ different obstetrician?

Just wanted to add my story. I had almost exactly the same story as you for my first labour with DD1 (baby back to back, long labour, rotational forceps delivery in theatre and a repaired third degree tear).

When I fell pregnant with DD2, 21 months later, both midwives AND consultant were confident in encouraging me to have another vaginal birth, saying that my chance of tearing again was no more or less than any other birth. However I WAS offered an ELCS if I wanted it. I chose to try for another vaginal birth and DD2 was born vaginally after a four hour labour, gas and air, and the experience was a world away from my first birth!

However.......just as she was crowning the midwives realised she was presenting with her hand up at her face and although we took things slowly (or as slowly as you can at that stage! ) I managed to tear again along the same scar! I was taken into theatre and stitched (it was obv another third degree tear) and the consultant took AGES! However the repair was fantastic and my recovery was much quicker this time (without the bruising from the forceps and the long tiring labour!).

So I think what I'm trying to say is that labour was much quicker and easier second time round and that although I DID tear again, my repair was excellent and I have been left with no lasting damage thankfully.

Having said that, I am now pregnant with DC3 and have opted for an ELCS, mainly due to the fact that consultant has advised there MAY now be a weakness along that scar and awful SPD.........hope that helps?!

I had mild pre-eclampsia, labour started at 39+5, went on for a day and a half, through four changes of midwives as shifts changed, had an epidural, ended up with forceps, had a tear in my cervix, lost so much blood they had to mop the floor and wipe the walls too. I spent five days in hospital with DD, we both had IV antibiotics, I had a transfusion. She was rubbish at bf and we ended up back in hospital at day 10 as she'd lost so much weight. I could barely sit down for over three weeks due to the soreness down below, which was tons worse than labour pain.

DD2 was born at 40+2, labour lasted four hours and she was delivered with no pain relief other than gas and air early on. A couple of small stitches, which healed quickly. She bf for eight months, incidentally.

So, yes, I did do it again, and it couldn't have been more different.

I am not getting into a debate about what I would or wouldn't do in various medical situations with a 20% risk.

I am telling the OP about what I chose to do for my second birth, as I had a similar set of circumstances to her in my first birth.

I haven't said she should do the same, that's not for me to do. I read the Ragged Bits thread before making my decision.

If the OP chooses a CS then she certainly shouldn't feel any guilt. But then nor should she for choosing a VB.

I am bowing out of this thread now as I don't see how us further discussing what I would/wouldn't do in other situations is helpful to the OP.

CoteDAzur You make it sound very black and white but you are not considering the risks of the operation. Plenty of people if told that there was a 20% chance of death, would quite correctly infer that there was an 80% not. On this basis some would say they would wait and see how things turned out. A further group of people would ask ' how successful is the op' before they made a decision.

OP, I'm not sure what the best course of action is, as both VB and CS have pros and cons. What I will say is that I'm glad you have a supportive health care professional listening to your concerns.

In the end it's up to you, but you'd have zero need to feel guilty if you took the CS.

i had a section with ds1 after a failed induction. pregnant with number 2 and am pushing for section. as others have said it is not as bad as made out, you get your baby straight away and everyon says planned sections are even better than emergancy ones like mine. Like others i was out after 2 days, off meds by day 4 and could even run the hoover around after a week, driving after 4 weeks. its not bad.

Personally I dont think anything is worth risking being incontinence, wether it is permanent or not. I imagine it would be easier to look after 2 childrens after a section, then having to deal with them, and learning how to manage your own new health condition. Also have you thought about how and short or long term damage would effect your confidence. Would you be comfortable going to groups, meeting new people while trying to manage your problems, and then silly things like swimming(not sure how they repair incontinence), would you be able to do this?

Shag

"I myself have issues following my third birth" Shag were you told by a consultant that you might be fecully incontinent for life? If not I am not sure how your issues are relavant.

I am not suggesting a worst case scenario to op at all - her CONSULTANT did. I know you dont like medical proffessionals but I wonder why you are so keen to pitch your knowledge agaisnt that of a medical proffesional who has seen op - and made a judgement call on her issues.

"Then I saw the consultant who basically said that if I was to do similar damage (tear-wise) as last time they wouldn't be able to repair me as well and I might be left feacally incontinent, possibly forever, and basically advised me that I should have an Elcs which I really wasn't expecting. "

Shag says.....

"For the op the best outcome and the preferred on would be a straightforward v/b, which actually is the outcome which is most likely if you look at the stats."

Shag, the consultant has looked at ops case and made this call, can you tell me based on ops problems why you would oppose the consutlants view> because you talk like you are a consultant yourself.

Shag have you also read any threads on here about women suffering with incontinese problems?

Even if YOU have a colostomy bag - and dont have a care in the world about it - that doesnt mean that OP or anyone else wont actually find it rather harder than that.

I know fully well that women dont get divorced and live single lives if they have bowl problems.

HOwever - op does sound worried about a lifetime of problems and if it does get her down, down the line, she might be wodnering " WHAT IF" so might her partner - having to help her. ....

OP already sounds " cautious" about a c section - tbh, I am not sure there is a lady in the land who would ever approach a surgical operation glibly.

OP certainly doesnt - hence why she has posted on here....

"I don't know why I feel so guilty going for a section for the risks for me rather than the baby? "

Feeling guilty is NOT a reason to turn down a section.

I am not sure that your stats make any difference in this situtation, where a lady has potentially got a problem that may be very serious should it happen again. Its a big risk she is thinking about.

"Eliza - there are many many women with bowel problems following birth who are not divorced, friendless and suicidal. The vast majority in fact."

Really? Alot of women may not like admitting they have a problem so tbh any "STATS" you had on that - I would treat with a little bit of caution. Your stats may be skewed because alot of women out there may be suffering without disclosing full details to thier DH.

You are very very keen to push HB's etc and I think thats great, but I dont understand why you also refuse to ignore and not aknowldge that MANY women have ECS and ELC and alot of them say it was " fabulous, wonderful, calm" and they had good recovires.

What works for you SHAG, and what criterias make you happy, may not actually work for an entirly different human being.

It is effing black and white. It would be insanity to not go for an elCS if given 20% odds of lifelong faecal incontinence, and it is disingenuous to call those odds "reassuring".

I would have to differ - to you it may be black and white - to others it would not be. Each woman has to weigh up the balance of risks for herself.

Apologies - posting on phone and missed the mention of a 20% likelyhood of severe fecal incontinence. If the OP has been given these figures by her obstetrician baesd on the specifics of her obstetric history , and this is backed up with clinical evidence then obviously that puts a different spin on things.

I'm probably a bit swayed also by the fact that the only 2 people I know personally who have ended up with a colostomy following birth both had elective c/s (one had placenta percreta - scar tissue from previous c/s resulted in placenta growing through and attaching to bowel ).

Can't post at length today anyway so will have a look at this thread later. I just tend to have a bit of a knee jerk response to the lip licking catastrophising about bowel and bladder problems I sometimes detect in those posters banging the drum for the all out wonderfulness of planned c/s .

"I sometimes detect in those posters banging the drum for the all out wonderfulness of planned c/s ."

Everything has its place and ALOT of women are VERY grateful and HAPPY that they have had sections and ELC.

I am not banging any drum at all - I cant as I have only had one labour, textbook - and I am considering my options for no2 - ELC, hospital or HB, which is why i am always looking at these boards for proper RL stories from rounded sensible posters.

I am not banging a drum for c sections at all -but personally i have been very very taken aback by the sheer amount of posters who have had them on these boards who do use words like " wonderful, lovley, fabuluous" to desciribe them. In RL I have heard the same; but i pick up on a feeling that they shouldnt really admit it was great...I may be back on these boards posting with my ELC, or HB experience for good or bad to let others know - how it went for me.

Most posters however who do think ELC are a safe and viable option for women who want them. also tend i find to also agree that other ways of giving birth are equally as valid.

From what I have read though some zealots out there who are for HB are rigidly oposed to sections.....

Reading your posts about HB puts me off a great deal however.

"The whole problem with the world is that fools and fanatics are always so certain of themselves, and wiser people so full of doubts." Bertrand Russell

Shag - OP's advised her to have an elCS because if she tears like last time, they wouldn't be able to repair her and she would be left faecally incontinent, possibly forever.

It was Flisspaps who gave the stats of 17-25% for another bad tear, and I averaged & rounded it to 20% for argument's sake.

OP - It's insane to roll the dice when the stakes are so high.

i had a similar experience, my first labour was 44hrs and i tore really badly. my dd1 was back to back which ive read is one of the most painful types of labour and i agree! i have also read that with a back to back labour the head usually comes out at its widest point hence the tearing. im 5''10 and my midwife told me tall woman are more likely to have back to back labours as the baby has more room to get in the wrong postition.

i had my dd2 15months later and was terrified! if they had offered me a CS i would have bit there hand off!
but in the end i had a 2hr labour with no complications and no tearing. when it started i was pottering around the house (at 9pm) saying we will go to the hospital in the morning! i pretty quickll realised the baby was coming we drove to local hospital and 15mins later she was born. it did still hurt like hell though.
i personally think a small gap helps your body remember. good luck!!

I had a forceps delivery resulting in a 3b tear. I was advised that I would be offered an ELCS next time (if I want it) but unless I had suffered any issues from the previous tear then I could also opt for a VB. My consultant said there would only be a 5% chance of a 3rd or 4th degree tear the next time. I think this was on the basis that there had been a full recovery with no ongoing issues.

Hope this helps as it is something I know I will have to think very hard about when the time comes and it will not be an easy decision for me to make so I completely sympathise with what your are going through right now. I wish I could just accept that when the time comes I should just take the offer of the CS but, although I have heard many positive stories about them, the thought of a CS terrifies me!

Flick - I was told that scar tissue (in my case, from episiotomy) doesn't stretch as well as normal tissue, so your chances of tearing badly are worse if you have already torn before and now have scar tissue there.

In other words, 5% sounds optimistic. I was told there was 50% chance of another huge episiotomy in my future, which is about when I started pushing for an elCS.

I'm planning for a second VB in a few weeks after suffering a 3a tear last time. As someone else mentioned up thread, my understanding is that the most important factors for risk are a) whether you've had any ongoing issues with bowel/bladder incontinence and b) what degree of tear you've had.

I've been told that my repair is good, my tissue is good, and that I have no more risk than anyone else of tearing badly again. But to avoid forceps, positioning is important, and to plan for as managed a delivery as possible.

The key thing for the OP is that she's had RL advice from a consultant - none of this theoretical odds and ideology discussion seems remotely relevant compared to that (and tbh I'd find it quite stressful if this was my thread!). Every women has a different body and each assessment should therefore be individual.

OP - have you thought about seeing a different consultant for a second opinion? Might help to get some more information?

I have had a forceps delivery resulting in 3rd degree tear and an EMCS. I found the recovery pretty much the same with both. If I were to have another baby I would request an ELCS, mainly due to concerns over potential continence problems, which I would find horrendous.
I found that although the c section was sore for the first week or two, I felt well recovered after that. Where as, this time with the 3rd degree tear I still have some soreness and my muscle control 'down below' is still weak.
In terms of caring for your LO, I don't think there is a huge difference whichever path you choose. It's hard when you have had a previous tough labour as it throws up these sorts of decisions.
Congratulations on your pregnancy. X

I've done a lot of research on this. I'm pregnant with second child after long, horrible first birth - baby was back to back, 4.18 kg (9 llb 4) , born in compound presentation (arm by shoulder), ventouse as decels in hb and meconium, 3b tear. Repaired in surgery - all fine now.

First wanted to put down some of the statistics. Risk factors for a 3rd or 4th degree tear are (from RCOG www.rcog.org.uk/files/rcog-corp/GTG2911022011.pdf):

birth weight over 4 kg (up to 2%)
persistent occipitoposterior position (up to 3%)
nulliparity (up to 4%)
induction of labour (up to 2%)
epidural analgesia (up to 2%)
second stage longer than 1 hour (up to 4%)
shoulder dystocia (up to 4%)
midline episiotomy (up to 3%)
forceps delivery (up to 7%).

The chances of a 3rd or 4th degree tear for a first birth is 3%. The chances for a woman who has had a previous 3rd or 4th degree tear goes up slightly to 5%. However, the consultant who I saw (Mr Bidmead, Kings College Hospital) puts this down to medical professionals being better at spotting 3rd and 4th degree tears the second time around.

According to the RCOG, if you have a previous 3rd or 4th degree tear, there is a 17-24% chance of worsening symptoms of faecal incontinence, regardless of whether you tear.

My reasons for wanting an ELCS are as follows:

17-24% chance of worsening symptoms of FI, regardless of whether you tear, does not sound like very good odds to me.

Even if I do not have worsening FI soon after delivery of second child, as age and muscle tone deteriorates, it is likely I may have symptoms in later life. NB OP various doctors I have spoken to about this have not been able to give me any statistics on this. Would be interested though to hear from any older mums in my situation?

My tear is currently well healed - normal pressures on anal manometry, normal results on ultrasound and MRI. So I am not keen to disturb. NB OP - if you haven't already had these tests done, it might be a good idea to ask to have them done.

There is some protective effect of ELCS on pelvic floor due to avoiding future assisted delivery or other unforeseen risks such as compound presentation. NB OP if you decide to have a section, you should avoid labouring at all as it will defeat the object of having one.

Have weighed up relative risks of ELCS (looked at the 2011 NICE Guidelines on C Section) and VB and prefer the known risks of ELCS.

Have undergone counselling for birth trauma the unknown risks associated with VB are a considerable source of stress.

I had a similar first birth - except ventouse and forceps both failed and I ended up with an emergency CS.

Second time round was much faster so no epidural. I think I was better able to push etc... but baby still got stuck in the same place. This time ventouse worked though. I am glad I didn't have an ELCS

I would go for a second opinion if you can. When you saw the consultant first time you weren't expecting her advice to have an ELCS. This time you could ask what is the % chance of a bad tear and how does that compare with the % chance for someone without your history? How will they manage your labour? What are your options re: EMCS instead of forceps if it comes to that etc...

My other advice if you do go for a vaginal birth....I hired a doula. It was the best money I have ever spent - to have someone knowledgable and supportive there who had talked through with me what I wanted, and was not part of the hospital system.

The birth of my DS in 2010 was pretty horrendous, ending in a forcep delivery, 3b tear and episiotomy. Unfortunately I was left with fecal incontinence which triggered post-natal depression. It has improved vastly now and I don't have 'accidents' but I am having another baby in September by elective c section. This was advised before I even got pregnant. The tissue in your bottom slackens over time anyway (collagen) so you are more likely to have problems with that than a c section scar which will heal back to normal. Please don't take the risk - the incontinence is horrendous and soul destroying when dealing with a new born baby. Good luck xx