Third degree tear and incontinence...

[GangAftAgley]

I know that there have been a few threads on this, but some seem to be from a few years ago, and I'd really like to hear people's experiences and advice (although I realise this is quite personal and potentially upsetting). This has really upset me and I am trying to be positive but can't stop thinking about the impact, past and potentially in future, on my body.

In short, I had a terrible first birth experience with dd1, with a long labour, an episiotomy, a third degree tear, a subsequent operation to repair (nice) and a post-partum hemorrhage. Dd1 was fine, for which I am eternally grateful.

I have recovered really well and have had no symptoms, for which I am very grateful, and am now pregnant with dc2. I was becoming quite upset at the prospect of another birth like that, so threw myself with some enthusiasm/desperation into hypnobirthing and pelvic floor exercises! I was beginning to feel much more positive, however after an appt with a consultant I ended up discussing the chances and statistics of recurring complications - specifically incontinence. According to the guidelines from RCOG I have a 17-24% of developing some degree of incontinence in the future following a third degree tear, although I don't think this is based on massively extensive studies/research, but I could be wrong.

This whole thing has really knocked me. I'd been feeling so much more positive following hypnobirthing and that whole positive approach, but now I just feel like unless I opt for a CS, I'm signing myself up to a future of faecal incontinence. I really wanted to go for a vaginal delivery, if I could, but now I just don't know what to think. I really didn't want a CS, but the thought of potentially lifelong incontinence is making me think I should just have one (although apparently this is riskier if I ended up having a third dc??) I am booked in to see a gynae physio and have seen two midwives who talked me through the options.

I know I should feel lucky that I even have some options, but tbh I just feel really upset about the whole thing. I hope I haven't phrased this in an upsetting way or anything - I realise this is quite emotive. Has anyone any thoughts/advice?

Hi there,
I can understand your fears and as women incontinence is something we must all think about for our future health. Studies are based on a general population, how many of that population do you think did regular pelvic floor exercises or took an active approach to managing their feminine health? We ALL have the risk of incontinence, this increases with pregnancy, then vaginal delivery, then severe tears etc, however it is still rare and it is still very treatable. There are a number of things your can do to decrease your risk of tearing and I would be interested to know what position you birth in, whether you had pain meds, whether you had an assisted delivery etc. This time around you need to plan a birth which works with your body, positions that allow the perineum to stretch, avoid medications that stop you feeling the birth (epidural etc) you can also try massaging the perineum. When considering this upcoming birth consider the risks associated with the alternative options too, caesarean section comes with its own risk factors for your future health and is also more of a risk for your baby. I wish you all the best and hope you can continue to feel positive and plan a birth that maximises your chances of being fit and well afterwards :)

Thank you welshdoula, that's such a kind post. I think last time was the exact opposite of the kind of birth you talk about - I had an epidural, on my back, not very active at all, although it wasn't an assisted delivery, but looking back it's the opposite of what I'm reading about now (although I realise this may be the right choice for some people.) And before my appointment with the consultant this week, I was certainly planning a lot more for an active, relaxed birth using different positions, whereas before in all honesty I think I just thought the less I knew the better. Do drugs like pethidine and diamorphine increase chances of tearing/complications in your experience?

I've never really thought of incontinence as treatable, and I suppose I have just been thinking about the very worst case scenario. I followed the gynae physio's instructions to the letter after the birth last time and now do pelvic floor exercises religiously as they helped so much in the past. I've also read about perineal massage and although it sounds awful I'm going to do it as it sounds as though it is one of the few things I can actually do to help.

Thank you so much for your reassuring post - it's nice to feel as though there is still a hope for the birth I would like and with incontinence not necessarily a foregone conclusion.

I'm interested in what other people have to say about this - DD is only 3.5 months but another child is a possibility in the future.

I ended up with a fourth degree tear after a forceps delivery, fortunately I've healed well, but DD turned her head in the birth canal and got well and truly stuck. Up until then I had done everything possible to have an unassisted delivery - perineal massage while pregnant, staying mobile during labour, I pushed for an hour alternating between kneeling up holding onto the bed, and squatting on a birthing stool, so ideal positioning in theory. This to me means that with the best will, and effort, in the world, assisted deliveries and tears can happen.

I didn't mean to imply that these sort of complications only happen with less active births, TheOriginal, I just think looking back if I'd have done everything you did at least I would have known I did everything within my control to avoid them. As you say, sometimes things happen with babies that require intervention beyond our control.

I'm just hoping that a second birth might naturally be a lot easier than a first one, but I'm still wavering on a daily basis between a CS and a vaginal birth. I'm trying to be positive but it is really difficult and is beginning to really get me down, which is the exact opposite of the approach that hypnobirthing emphasises!

One thing that you need, I think, is to see a gynae to look at how well your pelvic floor has healed. I saw a consultant after a third degree tear, and he carried out an anal ultrasound (nice!) and said he would do another one if I was to get pregnant again. Then I moved house and I'm not sure if that treatment is standard!

So if you really want a VB, there are checks that can be done to see if your anatomy is up to it.

Me personally, I know my anatomy isn't up to it (I've had some gynae issues) so I will be pushing for CS. I'd imagine it's far easier to get "permission" for a VB after third degree tear than it is a CS, so if you know what you want, you will be supported.

I had a bad tear with my first birth and had continence problems afterwards. The birth was actually a pretty positive experience up until the point I tore: drug free, encouraged to move and choose position, wonderful supportive experienced midwife (I remember she told me she was a community mw and normally did home births but had been called in because the unit was busy- so she was very relaxed and hands-off). I think for some of us tearing might be just one of those things you can't do much to prevent.

I did have continence problems after the birth, and it is just the most awful thing.

I had an elective section for my second. It was probably the best day of my life! I have said this before on MN but I really feel it healed the psychological and emotional scars caused by the tear. It was 100% a positive birth experience and definitely the right decision for me.

It is of course a very personal decision, but for me the key thing was that birth will be just one day in your whole life, and you may end up having a CS even if you plan a water birth, it's inherently unpredictable - but incontinence would affect the whole of the rest of your life. And is the ideal of a "natural" birth worth an approximately 1-in-5 risk of incontinence? Obviously, that gives a 4-in-5 chance of not suffering incontinence, so for you the answer to that question may well be yes. For me the answer was no.

I found all the medical staff (including midwives) were very supportive of my right to choose and would have accepted my wishes either way, but it was clear that they all thought a CS carried less risk overall of future problems for me, and very little risk at all for the baby.

Recovery from the CS was far easier than the recovering from the tear, too.

I hope this is helpful and doesn't just throw you into even more uncertainty!

4th degree tear with DC1. Healed v well, almost no pain; I suppressed memories of labour etc. Some minor stress incontinence lingering a few years on.

DC2: did my research (thank you MN ), pushed for a consultant referral that my MW did everything in her power to stop. Consultant agreed to en ELCS in under 5 mins. He explained that the % risk of incontinence you mention is a best-case scenario ie if everything goes OK and there are no further tears. He said that in my situation he'd go for a section himself!

Like a pp I found my CS a healing experience (from an emotional pov). Recovery was no worse this time round; I was in more pain but so much more mobile and capable second time!.

Good luck op, I hope you reach a decision that works for you.

I'm choosing a section for this baby after third degree tear. I felt like I had been mutilated/'hacked' at and shown no respect in terms of my epis that was given prior to forceps. I have healed relatively well but still have urgency issues and emotionally can't risk another bad tear/being seperated from my baby for hours whilst I get put back together again

I had a bad 2 degree tear with my first, when I was pregnant with my ds2 I was really scared about going into labour because I was scared of tearing, I think my body was so scared I didn't go into labour and was induced instead.

This time I had a third degree tear, it's healed fine ( ultra sound test) but I donthibk as someone said above some people are more prone to tearing for whatever reason.

I couldn't have a natural birth again as I don't think I would be able push knowing I might damage myself further.

I couldn't consider a v birth.