Opinions re: Drs advice about preventing 3rd degree tear please.

[spidermam]

I've had 2 children. After the first birth I had a 3rd degree tear and after the second I had a 4th degree tear. I'm pregnant again!
I've just had my first appointment with the Ob/Gynae registrar and I was very surprised at what he recommended for the next birth.
He offered me a C-Section, but what he actually recommended was this:
Hospital birth, epidural, episiotomy and an instrumental delivery. He actually suggested a forceps at one point!
Now, I'm really confused because I thought that an epidural and an instumental delivery esp. a forceps actually INCREASED your chances of tearing!
His rationalle for the above was that a prolonged 2nd stage increased the risks of having a tear. However, at my second birth I was only pushing for 10mins.
I have been trawling the internet for any info to back up his ideas and have only been able to find things contradicting it. I want to gain all the relevent information before making a decision. Can anybody find anything about his recommendations, or has anybody any opinions to offer please?

What a load of rubbish, complete and utter tosh, unless you healed up really well the last two times, then don't even consider having a vaginal birth, especially not with all those interventions. It would be an accident waiting to happen. I have never heard anyone suggesting such a bizzare thing, I would wonder about his/her qualifications, or whether they have just had their knuckles wrapped for having high cs rates. (I am a midwife by the way)!Congratulations on your pregnancy.

I do feel that I have healed up very well after the second birth. This may be that the 3rd degree tear after the 1st birth was undiagnosed so wasn't repaired very well, so having the 4th degree tear second time round was almost like it being re-fasioned!
Its a bit poor of the dr to recommend something based on lowering c-section rates. Though it did cross my mind. Surely if he leaves me faecally incontinent following his interventions it would be worse?

If I were you I would ask to see the consultant and see what he/she recommends, I can't believe that this advice would have come from a consultant.

If you healed well last time and would like to give it a go this time, then the best thing to do would be to wait until 36 weeks or so, see how big baby seems to be, what position it is in etc before deciding.

If you have a vb I would personally think that the best thing to do would be to have a natural birth with no intervention and to try and breathe the baby out at the end, not to push at all, the make the second stage as slow as possible. Although a long second stage may make the problem worse, 15 minutes and more controlled would probably be better than 5 minutes if you see what I mean.

Another thing is you may have a really short perineum, if I were you I would ask a dr (not the one you have just seen though!) to examine you and see how things are looking now. I have only looked after one woman who had a fourth degree tear, and to me it was obvious a few hours before she delivered that she had a really short perineum. Obviously she may have had an intact perineum or a small tear, but I wasn't surprised when she had a 4th degree tear based on her anatomy. I had done an episiotomy as well which I don't do often, but felt in her case that it may prevent a tear (there is no good research to support this, but in her case I felt need to direct the tear away from her bum, there were also other reasons to do it at the time)

Good luck, hope the decision making is not too difficult!

Thanks for your advice. I am leaning towards having a VB since I don't relish the idea of surgery. My babies have all been big. My DD 8 pounds 8 oz and my DS 10 pounds and 2 oz! I'm having a diabetes test soon. Hopefully the next one is smaller!

i've read this thread with interest as I posted a similar thread on the pregnancy topic bit. I had a 3rd degree tear with DS1 and then subsequent re-fashion 16 weeks later as the stitches did nto dissolve and there were uncomfortable lumps and bumps and bunching. The scar now feels absolutely fine and gives me no trouble. I am now 15 weeks pregnant with DC2 and worried the same thing might happen. My MW has referred me to the consultant and said I would be entitled to and elective C section, but I really want a VB. I actually really enjoyed the birth, it was 4 hours, although 1 hour of pushing (which might be why I tore, after reading what Maxbear says) and I seem to remember pushing for all I was worth, not breathing the baby out! He alos had his hand up by his face so this might have caused the tear as well?

I just don't want it to happen again so am wanting to find out how to minimise it. It was interesting to read your comment Maxbear about being able to wait until 36 weeks to see how the baby is lying. Midn you DS1 came at 37 weeks and was 6lbs 3oz so not exactly huge.

Hope you manage to make an informed decision! It does sound like complete rubbish what that consultant is saying!

I had a terrible time on my 1st birth. I had an epidural, episiotomy and ventouse delivery and had Post traumatic stress afterwards. It is interesting that you should say that you enjoyed your birth. My second birth, despite having a worse tear, was a fantastic experience. It was a water birth, at home. I felt it was a huge healing experience for me. Another reason why I am reluctant to go into hospital to have a C-section. And also it makes me even more worried about what the DR advised me to do since it is an exact replica of my traumatic 1st birth!

was just wondering whats a fourth degree tear? I though third was all the way through.

I had a 3rd degree tear with 1st labour, stitched and then tore further.

Offered elective with 2nd by female consultant but advised vb by strongly anti-surgery mw. What I did have in the end was a guaranteed epidural and a vb, no problems.

HOWEVER, with your history of 2 tears you are statistically unusual; it might suggest your tissue is particularly friable - has anyone examined it?

What also I now feel the mws never gave enough consideration to was my future continence. Women with 3rd and 4th degree tears are more likely to have incontinence problems post menopause. If in your situation (or if I went on to have a 3rd) I'd opt for an elective.

Trikken: A 3rd degree tear there is damage to the external anal sphincter and in a 4th there is damage to the internal anal sphincter.
Heated: An elective is an option for me. Just wanted to know what all the options were and was surprised when dr gave me his advice. In my 2nd birth the midwives were encouraging me to push when I didn't have the urge. Also pushed the head and shoulders out. This time, if I go for VB am hoping not to do this. Did you have any other interventions e.g episitomy or instumental delivery. What was the reason given to you for the epidural? Was it just pain relief?

thanks for explaining that for me. i didnt know that could happen.

I had a traumatic delivery 1st time round - mw didn't believe I could get to 2nd stage so quickly and sent me home, returned in car very promptly, dh convinced ds would be delivered into the footwell! However, baby got stuck, gas and air had no effect, and I then laboured for a further 5 agonizing hours without pain relief trying to push him out, having torn quite early on in the procedure. Ds born blue but ok. There were further complications later.

The rationale behind guaranteed epidural was that it would slow my labour down (was still 5 hours from start to finish) and allow for controlled pushing when I was meant to - and in that it succeeded totally.

However, having had conflicting advice, I decided purely on the stats which say that 75% of women after 3rd degree or worse labours first time round, don't tear or tear to the same degree 2nd time. Of those 25% who do tear, 75% achieve good or better results post surgical repair.

The fact that you have had a 3rd, followed by 4th degree tear would concern me. Did you have any problems with incontinence?

That's Ok! Glad I enlightened you on the loveliness of childbirth!!

Just asked a very similar question, not having found this thread earlier. I too had a third degree tear with my dd, and am worried about it reopening if I go for another vb. Tearing doesn't bother me, but incontinence does. I already have a few problems from last time (can't hold in farts - very embarrassing in public! ) and dread having worse problems if I have a second vb. HOwever really don't fancy a ceasarian as thats a definite cut. I just don't know what the chances are of a big tear again.
Let me know if you get any sources of good advice spidermam

Ginger,
The way I understand it is there isn't enough research into the subject of whether or not to give birth vaginally or by c-section following previous bad tear.
However, I think that if you have symptoms then there is a higher chace of them worsening with another VB. Though second time round your chances of tearing a less. But it is a very personal choice. Ichose to have a vb second time roung and despite the fact that I tore again it was definately the right choice for me. There is good info on the RCOG website and the RADMIN (radical midwives) website, which helped me make my decision. There are lots of other threads on MN about the subject.
I am worried that if I have another vb I am pushing my luck!! The choice for me at the moent is between a c-section and a vb at home with the least intervention possible. Giving birth in hospital with epidural etc.. seems to me to be an even higher risk.
Just wish someone would publish some new research with clear guidlines about what to do!! But that's unlikely to happen before I make my choice. There is no right or wrong. I try and think of what the worse case scenario is on both sides of the arguement, how likely it is to happen and whether I can live with the consequences.

Hi,
There are ladies on a thread here who may be able to give good advice, too.

thanks zippy

Thanks Zippysmum that thread you linked to is great.

At the moment its all hypothetical for me as I am only TTC baby number 2. I'm just a bit of a control freak and like to know exactly what is going to happen, which is just not possible with childbirth. Or childrearing for that matter!

Goodluck with pregnancy number 3 spidermam, I'll keep my fingers crossed you get an easy and tearfree labour this time.

I would definately agree with Maxbear regarding the slower, controlled second stage, and gently breathing the baby out rather than pushing. I am so surprised about the advice the consultant has given- possibly the worst advice of all for your situation.
This is a big decision for you and deserves lots of internet research to weigh up your options between a natural vaginal birth with gentle second stage, and an elective section. Please don't even consider the forceps advice.
Good luck.
Lou x

Thanks Lou.
I'm glad people agree with me about his advice being strange. I just can't imagine why he would give such illogical recommendations. Maybe he has a pathological fear of normal birth?!
It worries me that someone who should be more up to date with current research should advise such things. it actually makes me want to avoid hospital under any circumstances! Maybe I should speak to someone else about it or write a letter?

it seems there are contradictions everywhere as my mw told me during the final stage that i had to push otherwise they would be forced to intervene. is it really true that breathing through is all yo need otdo as that was what i was doing as they would not let me have G&A due to breathing through the contractions so i refused to push! if this is the case i may have a new approach to my impending third labour!

True Beboo, with the epidural I did very little pushing apart from at the very end, dd made her own way out virtually.

Radical midwives online is a good site here
Obstetric advice here

Sorry, bethoo!

Hiya, I have just had DC3. I too had a 3rd degree tear with DS2 and was terrified about what would happen 3rd time. My consultant offered me a c-section if I wanted one, but encouraged me to try a vaginal birth as there were no guarantees it would happen again. My DS2 was 9lb, I'm only 5ft and a size 8 so a very big baby for me. I was worried that I would have another big baby, but my DD was only 7lb11.

I too couldn't face surgery as I had 2 other dc's under 5 to look after so i went for the vaginal delivery.
I'm pleased to say it was fab, my best birth! I was in the pool but got out at the end to push as the midwife wanted to make sure i didn't tear again. I only had a graze and a small 2nd degree tear which didn't bleed or even need stitches. Within a few days it had all knitted back together and 13 weeks on i have had no problems.

i just wanted to share my experience with you to show that it can sometimes be ok!!! Good luck with whatever you decide to do

Thanks for the links heated.
And thanks for sharing your experience charlie.