Giving birth after previous 3rd degree tear

[zoobaby]

Can anyone offer any advice/info about their experiences of giving birth after previously having a 3rd degree tear?

Spoken to numerous staff at my hospital and they all have varying opinions (and levels of sympathy).

One obstetrician believed vaginal birth would be easier, another said they'd intervene earlier (episiotomy, which I had first time around with the tear), a midwife was non-commital, a consultant said consider CS.

It's 2 years later and I'm very emotional when talking about the entire experience. Obviously more traumatised than I thought. I think my greatest fear is urinary and faecal incontinence if I get another tear.

Please share your thoughts.

Thank you so much to every single person who has replied. I’m reading with interest.

It’s good to read positive experiences from people who have delivered a second or more time without any major problems [can’t believe you kept going so many times zzzzz. Sheesh!]. But equally nice to read that CS is not so bad. The idea totally scares the crap out of me, but so did induction.

Thomasstockman you have actually listed every single negative factor affecting me. Gulp. I agree with your view that there is a denial of obstetric injuries. You know, I actually experience it with my DP, who couldn’t understand my fears at the time and certainly doesn’t get my anxiety now.

Thank you seaoflove for the link. Interesting reading. I’m very lucky to be at a hospital where the consultant/obstetrician/surgeon (at any rate he’s a “Mr” rather than a “Dr”) said he’d have no qualms with booking ELCS based on my previous experience but he did say that there was no evidence to say that a 2nd delivery would be as bad as the first. I guess he needs to present both sides of the coin.

Your statement about “a wide definition of symptomatic” has actually made me think some more and do a bit of research. I know that Dr Internet isn’t the best to use, but I’ve found a couple of reputable pages that lead me to believe that I have anal sphincter damage already. Sorry if TMI, but I do sometimes have difficulty in wiping totally clean (was considering installing a bidet just the other day), which I put down to weakened muscles but didn’t actually consider this to be a form of incontinence (ah crap, literally). I still don’t think it’s proper incontinence, but surely it’s some proper damage.

Thomasstockman and skitter, you mention tests on sphincter control and talking to corectal surgeons, however I was never offered anything of this nature. Maybe it was because I said I thought everything was ok when I had my single check-up at 6 weeks. I wonder if now is the time to request some investigation? I’ll definitely ask at my next visit.

Would you mind sharing some links? I've also had issues with, um, wiping, so I'm interested.

I haven't had any tests since I had an ultrasound probe up the jacksie at 12 weeks postpartum (and things obviously weren't healed at that early stage) so I feel very much in the dark about how well I have healed internally.

Ditto re wiping. Rely on moist toilet paper. Rubbish.

I find There's nothing like faecal urgency and wind incontinence to brighten your day

I had a 3rd deg tear with dd1 and was offered Elcs for dd2 which I I am so glad I did, it was a much more pleasant experience and the recovery from the Elcs was a walk in the park compared to recovery from the tear. Now expecting dc3 and booked in for Elcs again. Also one with wiping issues.... But have never addressed this with any medical professional, not sure what can be done?!

Good grief Flossie! I mean this in the nicest way possible, but I truly hope you don't get too many moments that brighten your day! At the moment for me it's just wet paper. But what's to say that won't change with age? All I can say is hallelujah for bathrooms and toilet cubicles with a basin beside the toilet!

Honestly, I had a sleepless night thinking about this last night. I'm in the makesomenoise camp by asking what can be done? Exercises I'm guessing. Some website said you can have surgery but I doubt it's extensive enough damage to warrant that, plus who wants to make things worse? Maybe a women's physio or colorectal specialist as mentioned by thomas and skitter.

Sounds lovely seaoflove. I just had a good ol' fashioned finger investigation. Funny thing is, after giving birth, I wasn't the slightest bit embarrassed or uncomfortable. It's strange how your boundaries shift so suddenly and dramatically.

A couple of links...
I started out with NHS Choices which describes bowel incontinence in the generic sense of loss of bowel control, the definition I thought it meant - and was feeling eternally grateful that this wasn't happening to me.

Then I found the page from St Mark's Hospital which describes causes of control loss. It tells you about the external and internal sphincter muscles and what they do. The bit about wiping immediately resonated with me as that's my biggest bug-bear (I also take longer to actually go, but I'm happy to deal with that).

Finally a third site My Bowel which again mentions the muscles and has a couple of videos so you can visualise.

I'm finding this thread really helpful as I'm facing the same thing. I'm 18w with dc3 and had a 3rd degree tear with dc2 3.5 years ago.

I didn't have any follow up tests or ultrasounds - does anyone know if o can still have the anal ultrasound thingy now to assess the damage?
I really feel I want more information before making a decision.

I haven't had any really bad symptoms and seemed to recover well after being repaired in theatre, I think it was classed as 3a.
I have had a bit more urgency though when unwell which I never had before and (very embarrassed - is this a symptom?) I seem to be unable to hold in wind when having penetrative sex.... Went completely red when telling the midwife this.

[Poor DS being totally neglected this morning - it's a good thing he loves his cars]

I have my next appointment on Wednesday so I will definitely be asking. I'm thinking that a referral to women's physiotherapy will probably be offered. Maybe they make onward referrals from there if deemed necessary. Not sure if they'd do it now though, or after DC2 is born.

Read a Canadian physiotherapist's site which advocates exercises. Also came across a patient leaflet from St Mark's again. I'm not going to start doing these exercises without being instructed to do so, but it's interesting reading. Sounds like it could be helpful.

IWant, at least you only went red, I've been in tears each time I talk to someone different. Totally embarrassing, and I seriously can't prevent it.

From my experience, physio is what they will try first (biofeedback).

If things don't improve (and it takes daily exercises over 3/6 months or more) or worsen, the colorectal department can offer electrotherapy to try and restore nerve function or (worse in my view), teaching you colonic irrigation using an enema so you won't need the toilet for a few days.
My physio told me she has some patients like this. Typically they are in their 60s, had a physically traumatic birth but never had the physio rehabilitation that was needed right after the birth (no real woman's physio 40 years ago) nor maintained the exercises for life. My physio also says that women who use colonic irrigation find it a relief because their quality of life is improved compared to having to deal with faecal incontinence almost daily.
I know this all looks grim. I personally didn't take well at all when explained all this.

To finish on an hopefully more positive note, there are two great unknowns. The first is hereraditary. Why women who go through similar births suffer from urinary incontinence whilst others don't is not known/understood. The second is the impact daily pelvic floor exercises for life can have. I now view these exercises like brushing my teeth: must be done every day several times a day.

Hope this is not too grim but useful.

I don't know if this is useful or not but I'm due with DC2 in March. I had a borderline 3rd degree tear with DD1, basically very deep but healed ok. Required lots of stitches straight after birth, so I was away from DD for the first 45 mins of her life which I am sad about but honestly at the time didn't realise as i had been in labour 48 hrs (back to back labour).

Anyway this time they have offered me an ELCS and told me there's a 10% chance of me sustaining a tear that's as bad or worse as before and also a 10% risk of back to back labour again. The risks the first time were apparently 1-2%. I asked myself, if prior to that labour I had known what I would go through would I have chosen a ELCS and I would have because recovery was long and it was bloody painful. Saying that I am fine now but I've decided I wouldn't relax knowing it was possibly going to happen again. DD1 was quite small but had a very large had and I pushed for 2hrs...after 46hrs of labour. I've decided I don't want to risk it again because I know that the fear will inhibit my approach to labour.

My consultants have been incredibly supportive, midwives kind of don't seen to mind either way. Ultimately only you can decide, I've accepted neither option is ideal but at least this time I can (I think) be more prepared for what will happen.

I had third degree tear with 1st DS (water birth with no intervention) and did/felt exactly the same as you - I had quite a few consultations in the run up to birth to check growth progress by scans to assist me in the decision making.

Anyway amazingly I had no tearing with DS2 - water birth. The midwives all warned me against water birth and advised I get out at last minute so that they could be 'hands on ' and hold the perenium to slow down the arrival a bit. They said policy prevented them doing this in the pool. But at the last minute I found I couldn't get out of the water and the midwife put hands on anyway and I'm not sure what she did but it stopped the tearing. I also did the NCT stretch and breathe class - I found that this gave me a lot more control. I also resisted the gas (last time I was sky high on it).

Although ECS was an option I decided against it as the consultant said that / in my case - although the risk of something going wrong with c section was low - the impact of something going wrong with c section would be more traumatic than the impact of another 3rd degree tear.

Like you I was traumatised with first birth and recovery. I got pnd which I think was triggered by the tear and subsequent surgery to mend tear. I finally got 'closure' by having a 1-2-1 session with an NCT counsellor and a chat with the 'birth reflections' midwife.

It's so tough to get over the memory of a 3rd degree year. But after loads of thinking over months - and a LOT of visualisation and meditating that everything would be 'tear free' - the second birth was deliciously easy in comparison.

Only you can decide what's best for you and it's completely a personal decision. Good luck

I guess thomas maybe it has something to do with molecular make-up. Some people age terribly while others don't, get stretch marks, scarring etc. It's bloody annoying! You're very informed. I hope you've recovered well and don't face any of the things you've been educated and forewarned about.

Thanks for the opposing views Ilovechops and Newquay. I always fantisised that I'd be really strong-willed and able to do it as you describe Newquay but last time proved otherwise. I totally understand the fear that chops describes and at the moment I think that is the largest factor swinging my decision. Fear will probably get in my way and make things clamp shut. I was like you, and had to go immediately to theatre for stitching. Unfortunately I had to wait while they dealt with an EMCS in the other room, so it was about 3 hours before I returned to DS and DP.

I've been trying to justify opting for CS. I suppose I have to just make a decision and stick to it and keep reminding myself of all the factors that led me to make the decision, even if other people don't understand or raise their eyebrows at me. I have another complicating factor in that I have gestational diabetes and will absolutely be induced again. I was on syncto drip straight away plus all monitoring equipment. It wasn't conducive to moving around at all. Plus the contractions come pretty hard and fast (MW described it like a car going 0-100 in 5 seconds and she wasn't kidding). There was no gradual build up so my body and brain couldn't really compensate. I couldn't handle the pain at all and my resolve for minimal pain relief very quickly dissolved. Nausea prevented gas and air, and I was so afraid that the injection wouldn't relieve it and I'd have to wait hours for another that I agreed to "go large" and opt for epidural, which definitely made me stationery in the bed. I couldn't really feel contractions and had to rely on the MW telling me when to push. Not a lot of feeling down there, so I also probably contributed to my own demise by pushing in the wrong manner!

When I read about the most common causes of 3rd degree tear they are things like age, large baby, being on your back, prolonged pushing, forceps delivery, epististomy. Well, duh, it's no wonder I find myself in this predicament!

You don't need to justify opting for ELCS, zoobaby.

If, at the end of the day, you really can't face a vaginal birth because you'd be too frightened of tearing again (and I personally couldn't imagine going through labour in a bad frame of mind, or Making myself push whilst being terrified of doing myself damage) then that is a good enough reason. The potential health risks just bolster your case.

Avoiding an induction just sounds like an added bonus to me.

Thanks for the links btw, I'll take a look.

Tbh if there was a plan to induce me (which was on the cards as I'm over 40 and that's the policy where I am) then I may well have gone for an ECS. As it was DS came 10 days early so no need for induction. I've never had an operation so I naturally leaned towards natural delivery.

You totally do not have to justify ECS - the consultants/midwives I saw in run up simply said it was my decision and the 'fear' I had of a tear again was more than enough to justify my choice, my point being that you really really shouldn't worry about anyone else in this decision.

Absolutely - no justification required. This is your body, your mental state, your life. Whatever you decide is right for you.

That info from St Marks was really helpful to read - I had nothing from my NHS trust. I was referred to women's physio after DC1 and it made a big difference to my urinary continence and minor difference to faecal urgency. Recently had DC2 and am going to ask for another referral just because of the impact of carrying the pregnancy.

Here's to us

If only there was a "perfect solution". Alas, neither option is perfect.

It's true, neither is perfect. You just have to decide which is the least worst option.

Yep - least worst.

I think that's an apt description!

I had a very bad second first time round, a lot of stitches, agony... Second baby shot out without so much as a graze, 1 hour labour and 10 mins pushing, I was astounded as he had a big head as well

I'm having this dilemma. Though I'm 37.5 weeks so it's almost a done deal.
I was offered an ECS but it doesn't feel right to accept that. My consultant said it would be 'lazy' consulting to advise me to just go ahead and gave a section.
I had urge incontinence to start. & then all ok. Though I know my bottom/sphincter /bum hole whatever the hell I can call it is not the same as before. I seem to poo to one side and wiping takes ages. It's so annoying. Also piles that are now skin tags add to the joy of the wipe.

But I actually healed pretty well otherwise and don't have wind or urge incontinence. I never had the ultrasound tests so I don't actually know if there was much scar tissue and I have no idea what will happen when I'm menapausal...
I've been told I can have a perineum specialist which I think means a senior midwife for the push stage.
I'm also considering a duala.

I just feel like I will mourn something if I don't have a v birth. But of course I really really dont want to have another tear and pph

V difficult decision. No actual advice, sorry, just sharing! I started the thread about pain as well because as far as I'm concerned the epidural and forceps & episiotomy caused the tear.

I also don't understand about elective episiotomy. Does it really stop tearing ? It didn't in my case last time.

Well, according to the guidelines, there's no evidence that an elective episiotomy prevents 3rd/4th degree tears, no.

just to add my experience to the discussion...

I had a 3c tear 15 months ago with my first, now 23 weeks pregnant with my second. The tear was horrendous at first, but I seem to have recovered ok. No incontinence or urgency, but things definitely don't feel the same down there.

The consultant offered me an ELCS. She said that the chance of birth injury (which I take to mean 3rd degree and above) was 1% in a first birth, but that the chance of a repeat injury was 3%. It seems low, but not quite low enough for me to take the risk of long term incontinence. She said, "we were lucky the first time, I can't guarantee we'd be as lucky a second time".

The consultant also said that assessing how well I have healed (with endoanal scan) would not help my decision, because the results do not predict your risks of tearing again.

Also wanted to say I completely agree that birth injuries are brushed aside by many medical professionals, especially midwives, as something "normal" that women should expect and just put up with. That's not right.

I wish my midwife had given me an episiotomy! I'm convinced it would have prevented my tear.

My babies head was coming down, my hubby could see the hair but then she was going back up. I couldn't push her out easily as her head was huge. I think to myself surely they realised at that point she was too big for my foof to naturally push out!

But zoo if you do go for a natural birth and you are struggling to squeeze out the baby it is an option to ask for an episiotomy.

Did you find it hard to push out baby with your tear?

With me, I was so close to getting her out about 4/5 times but she just kept wooshing back up!

I think my episiotomy was elective. At least they asked me if I'd like to opt for it now or later. But is an episiotomy truly elective if, after a few hours of pushing and no joy (same experience as quitelikely), you're exhausted and they say "it's your choice, based on the monitoring of the baby we're happy to give another half hour of attempting to push, or we can perform the cut and assist with forceps right now".

They explained how I was fully dilated and how baby's head kept appearing and disappearing and I just had to get over that threshold. I actually remember thinking to myself "a whole other 30 minutes of exhaustion and then probably the same result or just go for the procedure this very minute, hmmm, no dilemma there". It was geting close to 48 hours from the beginning of the process and I just wanted everything over and done with.

I don't know if it's fair to say the episiotomy caused the tear (which I think it did), or whether I would have ripped right open without it (suspect that too). But I also think, before any of that, the circumstances of my induction contributed massively.

I don't think there's a "more organic" method of induction that I could request. Something that would gradually build up more like the majority of natural labours. I suppose it's all or nothing when it comes to forcing nature to get moving before it wants.