Fearful after previous 3rd degree tear; am now 39 weeks with number 2

[Polyxene]

I have looked through some threads about 3rd degree tears, episiotomies etc, but they haven't completely addressed my situation, so I'm posting here for any help or advice.

I had a 3rd degree tear with my first child, two and a half years ago. I had a good repair and healed fairly well, though my pelvic floor is pretty rubbish; though I feel to some extent I was lucky and don't want to push that luck. I was never offered any follow-up or debrief for this, and never thought to ask for one. But as this pregnancy has progressed, this issue has been dwelling more and more on my mind, so that now it is pretty much my main concern. It doesn't help that I have had a lot of contradictory advice from various different midwives, registrars and consultants (and indeed from my own internet researches), everything from elective c-section to just letting nature take its course. I understand that this is partly just because there is no one 'right' course, but sometimes I really yearn for the old-fashioned kind of consultant who would just tell you what to do!

Anyway, I do have a sort of a plan now, but I am still second-guessing myself all the time and don't feel entirely settled or happy. I should say that as far as it is possible to tell what went wrong last time, the main factors were probably largish size baby (9lb 5oz) plus rather quick labour (30 min 2nd stage) with fairly uncontrollable urge to push and not really feeling I knew what I was doing. I did end up delivering on my back, which may have been a factor (tried to do so in semi-kneeling/all-fours position, but wasn't getting anywhere.) (I say as far as possible to tell, as I am now at a different hospital, and though my notes were, I'm told, requested from there some two or three months ago, they never came through.)

So, I have felt all along that I wouldn't want a section, though I'm not quite sure why (mainly don't like the idea of long recovery, possible complications and/or infection.) In theory I like the idea of a natural birth without intervention, even a waterbirth or homebirth, but in practice I am too concerned about the possibility of another 3rd degree tear to want to risk it. This is especially the case as our local hospital is not great, is rather short-staffed, and I just don't feel confident that I would get the attention I'd need from an experienced midwife to manage my delivery well enough to avoid a tear. So I think I am opting for what feels like a 'least-bad' choice, which is to request an elective medio-lateral episiotomy, in the hopes that even if this does extend it will not be into the previously damaged area. I am told this means I shouldn't use the pool for pain relief earlier in labour, since then I would have to wait for 'waterlogged' tissue to dry out before I could be stitched up, which wouldn't be ideal. (My consultant has at least recommended I be stitched up by the registrar, which I'd hope would give better chance for good recovery.) The other thing I think I want to go for is an epidural, since in my case slowing down labour a bit might be a good thing, and especially it might take away some of the uncontrollable urge to push, so that I can more calmly do as the midwives direct. Ideally it seems I'd like to 'breathe' baby out rather than push him out, but I have no idea how to do this, the 'parentcraft' course I was on said there wasn't any point in covering breathing techniques for labour at all.

There are two other (unrelated?) factors to be considered. I have bad SPD, and the positions that are good for SPD are obviously pretty much out when looking at an epidural and episiotomy, but I think I am resigned to just having to lump that since the tearing issue is a greater concern to me. The other thing is that I have ME, which means that very active birthing is something I would be unable to do anyway. Possibly my lack of fitness going into labour is something that predisposes me to tearing, but there's not really anything I can do about that. (I have been going to an antenatal pilates class, also I've been doing perineal massage, as whether or not it will help I don't see it can do any harm.)

One concern is that my first labour was fairly quick, and I seem to take strongly after my mother and her mother, where second labour was even quicker. I have been advised to go into hospital as early as possible, but I do worry that I won't get there in time to have an epidural (I didn't last time, though in retrospect I could have gone in sooner) or that things will be really rushed when it comes to the episiotomy.

As I say, I am not entirely happy with any of this; it feels like less of a positive birth-plan, and more like attempting to make the best of a bad job. I would be grateful for any advice. As well as just trying to sort out the practical issues of what is the best approach to take, I just find the whole thing incredibly upsetting, and am really very frightened of giving birth at all. It's also obviously really late in the game to still be undecided and chopping and changing my mind; I did bring the issue up at my booking-in appointment and subsequent antenatal appts, when the conflicting advice started, but nothing has really been resolved and the closer to delivery I've come, the worse I have been feeling about it.

Sorry for epic length of post; I have lost all ability to be concise.

I lose the ability to be concise a long time ago lol so do not worry!

I have been experiencing similar emotions to you. I didnt have a third degree tear but had a rather large episiotomy without pain relief and am worried about tearing etc again. I got myself into quite a state a few weeks back but seem to be in that period (am 30 weeks) where will do anything to get baby out (on time) but the birth isnt close enough to worry me yet.

I think in your situation (and what ive been trying to ask myself) is what scares you about the situation and which option is worse for you?

Is it for example the actual tearing that scares you (eg pain) or is it the recovery or the possible complications afterwards? If its the pain of tearing then an epidural may be the answer? Could it be an option to be induced close to your date (not sure if they would do that or if its a sensible option) and set you up as soon as possible with the epidural? Is it possible to have that episiotomy but with pain relief first so you do not feel it?

Would a c section be an option that you would consider? Personally that option feels worse for me but everyone is different.

Do you have a doula? Is it too late to find one? Having someone knowledgeable and supportive in the room may help with the psychological and physical side of things.

Also do you think this might be affected by a case of things always seem worse when you worry about them? Thats not meant to sound patronising at all - but its one of the things I have been telling myself. When I imagine giving birth I am a lot more panicky that I actually was when I gave birth and I am trying to tell myself that in the process of it then I will have the adrenaline, the pain relief to keep me going and that I will cope at the time.

Maybe rather than trying to work out the best option it might help to try and work out the worst option and work backwards from there? Is there anyone you trust you can speak to about it from a medical perspective to really talk about your fears and emotions rather than just the physical side?

Sorry if Im rambling and not much help but I didnt want to leave your post without answering because I understand a lot of the emotions you are going through. xxxx

It sounds like you have figured it out pretty well actually Polyxene.

The reason for all the conflicting advice is that naturally everyone has their own opinion about this in the hospital, but there are very few people who actually have hands on experience of delivering someone who has had a prev 3' tear. The antenatal staff - probably never, the doctors - almost never as you almost certainly wont need an instrumental delivery, so it all comes down to a bunch of m/w who you have not spoken to which are the ones who work in l/w.

From my own experience (and I help deliver about 200 babies a year in a busy London L/W) I would say that if you had had a previous instrumental delivery, then there is a reason for the tear and I would not be so quick to do an episiotomy, and in this case, most women will have either intact or small 1st or second degree tears. Probably about 1 in 5 will need an episiotomy just to guide the tear away from the back passage.

If you had a 3' with no instruments, there is a slightly higher chance of you having another 3', so an epidural would be ideal, as would lying semi-recumbant (sitting up at 45') which helps to slow the birth down, and very controlled pushing - ie pushing until the baby is almost crowned and then breathing or panting the baby out. Very slowly! Upright positions are too fast and waterbirth - you cant see whats happening to the peri. All fours is probably ok but it can be difficult to do a quick epis if needed.
If you didnt have time for an epidural, Id try same as above but with local anaesthtic infiltration to the peri so that you would not feel if you needed an epis.

Other than what I have described, I would talk this through with you on admission so you were aware of the plan, and then at delivery, I would do the above and see how it went. Some people have a very short perineum (the space between the front and back), or they have friable, easily damaged skin and in this case I would do the episiotomy, but if you had ana average length perineum, and everything was stretching well, I would let you deliver without an epis, but with a very low threshold for an epis, so any early tearing or 'buttonholing' (which is where the peri starts to tear in the middle rather than at the vaginal end), I would do an epis.

I have never had a repeat 3' tear practicing this way, and of course, these are only my own thoughts, but I have at least gone through the delivery process with you.
But have a good talk with the delivery midwife when you go in and go through your plan, so you know what is going to happen and she knows that she had better do a good job!
I think you are right in not having a c/s - it really is not necessary (although psychologically it is right for some).

All the best and let us know how things go

Thank you so much waitingtobloom and Mintpurple for your responses.

Especially Mintpurple it is so reassuring to hear from someone like you. It hadn't occurred to me before but you're quite right of course that the one set of people I haven't talked to are the ones who are actually relevent and experienced in this. Hopefully the 'going in early' part of the plan will give me the chance to talk things through at the time. I am reassured that you think my plan is basically right - I had been second-guessing after hearing/reading so much about episiotomies being unnecessary and/or with their own problems re. recovery, and epidurals increasing risk of tearing. (I'm thinking that on the last point, while in general epidurals tend to lead to interventions and thus tears, in my case with history of quick labour that's less an issue and the slowing things down aspect is good.) I very much appreciate the advice on positioning and delivery strategy, that all makes a lot of sense. I'd been wondering about left lateral as a good position, but I don't know how easy it is to do an epis from there?

waitingtobloom that didn't seem rambly at all, and was very helful, thanks! That makes a lot of sense to try to focus on and narrow down exactly what I am scared of, rather than just being overwhelmed by a whole amorphous lot of panic, but I hadn't thought of that at all before. Now I do, I think my main concern is avoiding complications/aftereffects as much as possible, which is one reason I also don't like the c-section option. So from that point of view the plan I have at the moment does seem like the best one. I think the panic comes in from worrying that it won't work out according to the plan, and there I think you have a good point about things seeming worse when I worry about them. Oddly I wasn't much worried about the birth at all last time, and somehow I feel afterwards as if I should have been more worried, so maybe this time I am 'overcompensating' by going too much the other way. Which really doesn't make sense at all, so I think I should try to focus on being a bit more relaxed about things! It does feel oddly comforting to hear from someone who is experiencing similar emotions to me, although obviously I wouldn't wish the situation on anyone, and I hope you have a good resolution and good birth experience too.

In retrospect I think I probably should have looked into having a doula, though money is a bit of an issue, but now with a week to do till EDD I think trying to find one at this point would just be added stress. I intend to make sure DH who will be there is very well prepared to be my advocate, and go through the birth-plan thoroughly with him.

Thanks again!

"I think the panic comes in from worrying that it won't work out according to the plan" - yes this is one of my fears. If I knew I was definitely going to tear then I think I would worry less - does that sound completely stupid?! Kind of like I cant do anything about it so would just accept it, deal with it and get on with it. Im not for some reason worried about the contractions as I know they will hurt...

So therefore I think a plan where you are in control and deal with the situation might be a fab idea for you. A well controlled pain relieved episiotomy in this situation is likely to reduce your fear and worry (which in turn would make things more difficult).

It is strangely comforting knowing others are going through the same thing - but likewise - wouldnt wish it on anyone!

I really hope you get the birth you want - let us know how it goes xx

I had a 3rd degree tear with DD, she was a smallish baby, just 7lbs, but I had a very fast labour, and she just popped out like a champagne cork! No instruments involved, just very fast birth.

I have lost my nerve completely over delivering vaginally again, I have healed well but I am terrified of tearing again and potential fecal incontinence so I am requesting an elective C-section, which I am also frightened of having!

Just want to wish you the best of luck with the birth.

I had a 3rd degree tear with DS1. I had a wuick labour and the pushing ended up not being controlled and the whole of him shot out in one go. I was worried about this happening again second time too.

Hopefully my positive story will help you feel better about it. I had a home birth with DS2, and because the midwives knew about my previous tear and concerns with it, they made sure that the pushing was controlled. I ended up with a 2nd degree tear, which obviously wasn't ideal, but much better than before.

It won't necessarily happen again to you, and as others said if you discuss it with the mw's when you get there and they know your fears it will help.

Good luck

I've also found it very helpful to read this - I had a 2nd degree tear (ventouse delivery) with no pain relief which took a long time to heal and am terrified of the same again especially as I am likely to have another huge baby and fast labour. Its good to know that without instruments there is a lower chance of a repeat tear.

Thinking about going through it again does lead to rising panic - the pain of tearing, the feeling of being out of control, the pain afterwards. Am seeing an obstetrician next week to talk it through - really want to avoid a section so wondering what options there are really? Can I ask for a local anaesthetic in the perineum in case I tear if I don't have time for an epidural? My mother had an induction at 38wks for my brother who was expected to be big with a fast delivery - does this ever happen now?

Once again, thank you for all your responses.

waitingtobloom - no, that doesn't sound stupid at all! I think that's it, exactly, about what's in your control. It's like, being stuck in a traffic jam tends not to bother me, because there's nothing at all I can do about it so why worry, but things like trying to work out the best route to take in the first place are (partly) in my control, so I worry because it's 'my fault' if I've chosen 'wrong'; I think that's why I'm anxious now, trying to choose the best thing. I am feeling increasingly reassured, though, that this is the best course of action for me personally.

Minniethemoocher - I completely understand your choice to have an elective section in the circumstances; I understand quite a lot of women make that choice. For me, I am too afraid of a section, but I don't think that's a very rational fear either, it's just a personal thing. As I say, this whole thing does feel rather like just choosing the 'least-bad' option, instead of the 'best' option. Thanks very much for the good wishes, and I wish you all the best in return!

Mummyandi - Thank you so much for sharing your positive birth story, that does give me a lot of comfort!

MummyToOneForNow - glad raising this topic has proved helpful. If you haven't already, I understand you can request a 'debrief', going through your delivery notes from last time to understand what happened and help come up with a strategy for trying to avoid it again (I didn't learn about this possibility until too late as my notes were in a different hospital, but it sounds like a very good idea.) I don't know about early induction, but I do know my consultant suggested it would be best if I didn't go too much overdue (I was 10 days over last time), so that baby doesn't get even bigger, and also the head is softer earlier so 'squeezes to fit' better. Also he booked me in for a late scan at 37 weeks, to get an idea of how big baby was looking - maybe you could ask for this, then if it's looking particularly large you might have a good case for early induction? I get the impression induction tends to lead to a bit higher risk of interventions and thus tears/episiotomies (though I could be wrong) but maybe if you have a history of fast labour this is less an issue? Worth asking about, anyway, I'd imagine. Hope this is helpful, and hope the obstetrician can give you good advice!

I had a 3rd degree tear with DS, although it was because he was in an awkward position so I needed a forceps delivery. Didn't actually find it too traumatic though, and healed well.
I was offered an elective C-section in my second pregnancy, but like you polyxene, I found the lack of data and information on which to base my choice quite frustrating.
Chose a vaginal delivery, which was fine, small tear with a couple of stitches only. Delivered on my side, managed to control urge to push. The registrar suggested an episiotomy, but the midwife (who seemed very experienced) thought I would probably be OK without, as mintpurple suggested. No episiotomy as I trusted midwife more than registrar! Wouldn't have had time for an epidural, and didn't need one. It really was fine.
But I guess you had a 3rd degree tear for different reasons to me, which may make you slightly more at risk this time? It's so hard, trying to make a decision on such limited information. I felt like midwives very strongly favour no intervention, and doctors very strongly favour intervention, with no-one giving me any sensible advice inbetween, if you see what I mean?

this is not my personal experience but my friend had this problem too and was extremely concerned on baby number 2...really fearful, sleepless nights etc. She discussed with her doctor and he said there was a risk of the old scar tearing and even extending if she went naturally, as she had a very small baby...5 pounds...and a lot of damage.
They opted for an elective c section at 39 weeks. This baby was 7 pounds 6 oz so he said after it was lucky they had agreed on c section as my friend has a very small frame.

My friend in hind sight says recovering from the c section was a lot easier than recovering from the 3rd degree tear!

I know every one is different so i suggest you discuss it at length and make an informed decision that you are happy with