Tearing and needing stitches, can this be prevented?

[dejags]

When DS was born I was attended by four midwives the last of whom made me take things very slowly. She was a strong personality and didn't "allow" me to push when I should have been panting. She did have to yell at me a few times though to stop pushing.

I didn't tear or need stitches and I was wondering if this was the result of having an experienced midwife manage my 2nd stage or if tearing is more physiological (I think that's the correct phrase)?

Incidentally I had a failed epidural and no other pain relief. My labour was induced with syntocin due to my waters breaking and labour not starting spontaneously - it was 12 hours from start to finish.

First things first - make sure you don't mix up the glass and the iron! (Easily done if typing with one hand as well).
Back to topic... know of cases where woman has been told categorically she cannot deliver vaginally again because of damage caused previously. Appreciate that some women can - but some definitely can't.
There is a difference between 3rd and 4th degree isn't there? What's protocol at your place re sewing up? Would you be allowed to and if not what level of surgeon would do it? Also, do you think would be better to get colo-rectal surgeons in to do repair?

Consultant would do 3rd/4th degree repair or senior registrar if he was experienced. Midwives should NEVER perform such repairs as they are outwith their scope of practise. Have never seen colorectal surgeon called in but that is an issue that there has been some discussion around.

Have checked for spelling mistakes - this definately has to be recommended. I do not feel guilty posting on mumsnet as I am getting through the ironing. Wine is nearly gone though - that is a worry

Just realised I didn't answer the question properly. 3rd degree tear involves the anal sphincter. 4th degree involves the bowel. In the case of 4th degree tear I think the colorectal surgeon should be consulted but I do not think that often happens.

Thanks Leese you have confirmed what I had surmised. We did go through a spell earlier on where DS seemed to be stuck but with the help of the drip increasing my contractions managed to get him moving again. But you're right about the size of DS's head - I remember laying on the bed (because I delivered in that position) having feelings of shock at the sheer size of it (it was in the 90 odd percentile).

I had a 3rd degree tear with DS1 (10lb 1oz, "star gazer", rather too successful ventouse delivery!) repaired by the consultant in theatre (for what I seem to remember being 2 hours but I was rather spaced out by this point...)

Anyway, I had to go for an ultrasound scan to check the repair 10 weeks later and was told then that it had healed sufficiently well for me to have a normal delivery for any subsequent babies. DS2 was 2 weeks early and 8lb 4oz (and the right way up!) and I had a small "buttonhole" tear in the previous tear followed by an episiotomy to prevent further damage.

I assumed the ultrasound check was routine?

Thanks for clearing that up Mears - good job you stayed up late!
SoupDragon - yes, the scans are routine in some units, but not all. Some women with 3rd/4th degree tears do opt for c/s for subsequent deliveries after discussion with a consultant, but may not have had the luxury of a scan.
Out of interest, of those women I have assisted with a vaginal delivery who have had a previous 3rd degree tear, I have never seen a recurrence (largely because, as Mears points out, we offer routine episiotomy). as a 4th degree tear is a newer concept, have not yet come across a lady delivering vaginally after this, but I'm sure it's only a matter of time.
As in Mears' unit - all 3rd/4th degree tears are repaired by registrars/snr registars/ consultants.

First you have to find a woman that fancies giving birth vaginally after a bad fourth degree tear. Frankly, finding one that even wants to get pregnant again might be hard enough.

This (embarrasing) question is only indirectly related to the thread's title - but I'm sure our resident "experts" will be able to advise.

I had an episiotomoy plus a 2nd degree tear delivering ds (mid cavity forceps). The doctor stitched me up - no problems at the time.

But... is it normal, 23 months later, to still have difficulty using tampons (Lillets)? They just dont "stay in" properly any more - even though I went "up" a size to see if that would help. Should I mention it to my GP?

My pelvic floor is OK - no problems with stress or urge incontinence, I do a Pilates class weekly, which really helps maintain my pelvic floor.

Janz - you should be able to keep tampons in. Despite the exercises you are doing you are perhaps not exercising in the most effective way.You could be referred to a physiotherapist who can assess your pelvic floor function. Sometimes you need to strengthen your pelvic floor with weighted cones that are inserted into the vagina. Your GP can refer you. Definately worth going to see bout it. Although you do not have any urinary problems at the mmoment - you may in later life if there is an underlying problem. No need to feel embarassed.

Thanks mears - I'd been meaning to make an appointment and have just never got round to it.

The other thing I meant to mention was that my "opening" now seems much larger & feels all skew-wiff. I didn't initially bother about the difference, as I just assumed it was a "to be expected" consequence of child birth (especially with a ds with a head & weight on the 91st centile, when they'd been expecting a 7 pounder!).

The tear was on the side - is that relevant?

I can still (just) hold tampons in, but if I strain (eg when having a crap), then it half falls out - and also seems to have rotated so that it is parallel with the ground (if you see what I mean).

One of the other ladies at my Pilates class is also one of the physios at my maternity hospital (in fact, she does the hospital's Post Natal exercise classes - using some of the Pilates exercises) - I'll also have a word with her when the classes re-start at the end of the month.

Willow2 - you'd be surprised (I am - continually!)

Not sure if this is any help but I had a 3rd degree tear with ds. He was only 5lb 7oz, but after a long labour suddenly came very quickly! I was cut and tore as well. Had to be taken to theatre to be stiched (under the watchful eyes of dozens of med students!). I healed quickly with very little pain

Anyway, dd (6lb 12 1/2oz) was born vaginally. I asked for an episiotomy and was given a tiny one which was left to heal naturally rather than being stitched.

I think I probably suffered more afterwards with no2. I wasn't really worried or traumatised by either experience. I guess I was just lucky.

jenny2998 - sorry to hear about your 3rd degree tear, but glad you healed well. Sometimes it is the case that women feel less pain after a more extensive tear, rather than a smaller one which should not (in theory) be as uncomfy - I stress that this is SOMETIMES the case, not always. I figure that this is because the larger tears are always sutured, and follow up care is considered ie: pain relief prescribed, lactulose (or similar) given to ensure there is no constipation, ans sometimes physio follow up too if the tear is extensive.
In the case of smaller tears, these can be more painful initially, as some are left to heal naturally (as with yours jenny2998) - consequently these can sting when you go to the toilet to pee, and/or just be more uncomfy in general because they have not been sutured. Also smaller tears/grazes on the labia can be extremely uncomfortable for some women as these are in an awkward position - often ladies who have a perineal tear of some degree and a labial graze will complain only about the discomfort of the graze, and not at all about the perineal tear. So it goes, its not necessarily the bigger the tear, the worse the experience afterward, although it is also recognised that some women with larger areas of perineal trauma can suffer terribly, and need lots of subsequent follow up care.

Any advice, or similar experiences, please?

I had 2nd degree tear and plenty of stitches. The wound didn't heal properly, and after 2 or 3 cauterisations, I was finally restitched nearly 10 months after the birth. This involved cutting away a patch of necrotic tissue inside.

DS is now nearly 2 and I still have pain, but strangely it seems to be more on the outside rather than inside. No-one can find anything wrong and I am sooooooo fed up and humiliated with being poked about. Even wiping myself after weeing can be uncomfortable. Not to mention sex - to add insult to injury (ha ha ha) I seem to have lost sensation on the inside!

Has anyone any idea what on earth is going on here?

Forgot to mention that I'm pregnant again and half panicking about the thought of stitches!

wmf - is the pain there all the time? Sometimes women are aware of pain ( including myself) aroung the time of periods, especially externally in the stitch line - Possibly linked to hormonal changes. Comes and goes. Perhaps you might find things will feel better after this next baby. A friend of mine had similsr problems to you which improved a lot after her second baby.

Mears - I have found I experience real discomfort during my period. Thought it might be due to stitches - is this quite common then? Don't want to go in to detail in this post about my experience (you've probably gathered it wasn't fab) - but wondered if bad stitching could be responsible.

Willow2 - I don't think the discomfort around period time is anything to do with bad stitching. It is the fact that there is a scar there and the hormones affecting tissue elasticity etc.
Continual pain/pain on intercourse can mean that the repair was not done adequately. If that is the case then there should be a referral back to the gynaecologist who can then rectify the problem with corrective surgery if needed.
Sometimes though time is the great healer. For my friend it was almost a year.

What exactly is a 3rd or 4th degree tear? I had a 3 day labour and was consequently told I was too tired to be in any other position apart from lying down (though did try)- my perineum did not tear but both sides of my inner labia did, right down to the vaginal opening. I was stitched up but one side came undone and now I have one cobbled up lip and one that is in two bits. The opening does sometimes hurt during sex, though my GP did say this would get better "with use". I was wondering how this will affect my next birth (planning child no two - MADNESS) - could I tear even further in? Is there anything I could do to prevent tearing next time? (did do the perineum massage but infrequently, though was not this that ripped). Also, would they be able to repair the rip after the 2nd birth and if so, would I have to request it before hand? I understand that they would have to cut away the edges to make it all raw so it would heal together again. All this is making me squirm just thinking about it.

Gosh Cha - poor you - that sounds awful. Labial tears are usually not as extensive as that which you describe - you were extremely unfortunate. They can also prove to be far more painful postnatally than say a tear in the perineum. In brief, a third degree tear involves the perineum, and stretches from the vaginal opening, extending to the anal sphincter. A fourth degree tear extends further than the anal sphincter, usually involving the bowel. Both will need careful repair and follow up.
Labial tears are not classified in the same way ie 1st/2nd degree - they are just large or small tears (and yours sound large). Because you tore there before does not necessarily mean you will tear in the same place again - quite often labial tears are caused by babies hands/fingers alongside their heads as they are born, which can cause trauma in this area. there is nothing you can actively do to reduce the chances of tearing , tho' I would ask for referral to a consultant during your pregnancy, so your worries can be discussed. If you do tear in the same place, ask that a senior doctor sutures you to minimise any further problems - you could write this specifically on your birth plan, and make sure the midwife is aware when you go into labour of the problems you have had. If you do not tear in the same place, it is unlikely the doctor will want to cut and re-suture the labia immediately post delivery - this will usually be arranged for a later date, after an appointment with your consultant.

Leese - thanks so much for your words. Sympathy and reassurement was just what I needed after a long long day. Will do as you say when the time comes.

Good luck Cha - let us know what happens won't you?

My first child was born in 95. Long labour, couldn't dilate more than 6 cm, baby got distressed, had emergency caesarean. Second child was born in 98. Long labour again, baby got distressed, got to 10 cms but needed ventouse and forceps. I ended up with a third degree tear which was horrendous to recover from. My third child is due in 7 weeks. I've got the option of elective caesarian. I just don't know what to do. What are the chances of a normal delivery? Anyone got advice? I'd be grateful.

No midwife would agree with me I'm sure, but I'd for the nice elective cs, personally. It has to be a choice you feel happy and confident with though.

My gut feeling would be an elective c-section. What, in an ideal world do you want? Are you set on a "natural" birth?

My 1st labour was like your 2nd - long, ventouse, 3rd degree tear (big baby). However, I recovered from my tear with no problems whatsoever. 2nd time, I had an "elective episiotomy" so to speak since the tear began to look vulnerable. No further tearing and again recovered well. I'm trying to say that it can be better after a 3rd degree tear. I did have a lovely rectal ultrasound scan (no pictures were offered!) after DS1s birth to check how well the tear had healed and was told that there was no reason not to attempt a "natural" delivery for subsequent children. Have you had such a scan? I do know someone who was told that her tear had not healed very well and her next child was born by elective c-section to prevent further damage.