What did you do after a 3rd/4th degree tear?

[ealey]

I'm currently 34 weeks pregnant, and need to decide this week whether to book an elective c-section this week after suffering a 3rd degree tear during my last birth. I'm tending towards the c-section, as I feel that the consequences of a repeat performance would be too difficult to deal with, even if this is relatively unlikely. What I would like to know is what those mums who have been in this situation have done, and how you felt afterwards about your decision? I know these kinds of threads can easily end up as v-birth vs c-section battles, and I hope it doesn't because that really wouldn't be helpful! But I would love to hear about peoples' first hand experiences who have actually been in this situation. Thanking you for any contributions!

Sorry I'm not actually pregnant, but 3 months ago I had 4th degree tears with the birth of DS2.

The consultant I spoke to at my 6 week check up said that for a 3rd child I should have a v-birth as c-section risks damaging the bladder. He specialised in urology and has seen a lot of problems caused by c-sections.

If I am ever in a position where I am pregnant again I am afriad that I would probably go for an c-section. (Touch wood at the moment my healing has gone reasonably well). However, the risk of tearing again and possibly being left incontinent is too much for me.

A friend who had 4th degree tears saw a "bum" doctor who did some tests on her and told her that she had a lot of weekness in the pelvic floor area. She decided on a c-section because she also feared being left incontinent.

This is such a difficult decision. Good luck with whatever decision you make.

Hi,
I had a 3rd degree c tear and some damage to my bladder in my last pg. I am currently 38 weeks pg and due to have an elcs on Tuesday.

It has been a very difficult decision. I spoke to two consultants, my gp and my mw. My decision was made easier only by the fact that none of them felt another vaginal delivery was a good option for me.

I would not have chosen a cs and I am terrified about how it will go but, not quite as scared as I am of the prospect of being left with double incontinence.

My best advice would be to speak to all your mw and consultants and do what feel right for you. I would always advocate natural birth but I can't live with the consequences.

After a 3rd degree tear and bowel urge incontinence, I had a guaranteed epidural with pg no 2 which went brilliantly, was a fabulous experience. Very, very controlled delivery, not hard to push dd out at all. Hwr, I did deliberate for ages between vg and planned section and did lots of reading of obstetric research papers. I based my decision on the stats which are after a 3rd degree tear or worse, 75% go on to have a 'good or better' vb. Of the 25% who don't and opt for post-surgical repair, 75% achieve a 'good or better' result.

However, I am pg with no 3, and have had internal ultrasound to see the extent of the damage and strength of muscles, am awaiting results now, but they confirmed what I already knew, which is that my pelvic floor is very weak and that any bowel surgeon will advise a planned section. I will definitely be referred to Women's Health re pelvic floor after pg no3 but possibly may also have to have post-delivery work done. My internal debate is whether to have two bouts of surgery (section and bowel) or just one (bowel). I don't think mws give enough weight to incontinence issues resulting from childbirth once post-menopause.

I had an episiotomy and a 4th degree tear with DS2. (I don't do things by halves )

DS3 I had a few small tears and nothing more.

I had many bad tears and bladder and pelvic floor damage from DC1's birth with keillands forceps 16 months ago.

I have chosen an elective due to happen in June. I think a dodgy bladder is enough to cope with at 35 without more tears or forceps damage making my bowels incontinent too. I read a lot of online medical journals comparing risks.

I know cs can damage the bladder - but my pelvic floor will avoid the big stretch of the baby coming through; the elective will be calm and controlled reducing bladder risks; c-sections do cause a lot less bowel issues than vb; I feel already weak below so would rather not presume on a nice, slow, waterbirth when all I did last time to make that happen failed.

I have been told I can have a vb if I want - that the position DD got stuck in is 'unlikely' to happen again - but I think tearing is a real possibility or the need for forceps again. I don't want to take that risk.

Mw's and consultant are happy to agree an elective for me this time. My mw said it wasn't my birth that worried her so much as the 10 months of outpatient recovery that involved 2 consultants (urogynae and gynae) and a lot of physio support and is still not fixed completely. I don't plan on further children so am not concerned about the possible reduced fertility or scar risks in future.

I hope you find some peace with your choice - it may depend a lot on why you tore badly last time, but with that level of tearing already I would be really concerned and asking for a lot of checks/scans to check muscle tone etc.

Just to add - to echo the other poster - a lot of these incontinence issues will become more problematic after the menopause so the full extent of damage is not shown in the year or two afterwards. My mum and nan had early menopauses so I expect to be facing greater bladder problems by the time I am 40.

I completely agree with DinahRod. Midwives seem soooo ignorant about the long term effects of perineal trauma it beggars belief. I am NOT a fan of the medical model of childbirth, but the poor care and misinformation I have had from mws concerning my previous 3rd degree tear has made me lose faith in them fairly comprehensively.

I had gone on to have 2 VBs after my first 3rd deg tear. I have no regrets, I had a 1st deg and grazes respectively. That said, I do have urge bowel incontinense and constant incontinence of flatus (awful, embarassing etc etc.) I was strongly advised to have an elCS and declined, despite being under a lot of pressure. I don't regret that, it was the right choice for ME; I wouldn't dream of advising another woman on this matter, what is right is what is best for YOU. Like other people have said, read up; not just on MN which is purely anecdotal, and sometimes ill-informed as well, but read proper obstetrical research so that you know you are making an evidence-based and informed choice that YOU are happy with.

DinahRod I am interested to read that you think that any bowel surgeon will recommend an elCS. Mine commented that damage was wrought during the pregnancy, rather than the delivery itself. OP, have you seen a colorectal surgeon? If not, I would suggest you thought about asking for a referral so that you can gather more information to help you choose.

incontinence, sorry.

LittleSilver, it's what the colorectal surgeon and my obstetric consultant said: that the Royal College of Surgeons have recently changed their advice (well, in the 4 yrs since having dd) regarding 3rd and 4th degree tears involving the bowel and advise elective sections because of issues of incontinence post menopause. I'm not sure the MW body agree but I honestly don't think they see the long term picture, more the immediate result. A few pelvic floor exercises are not going to restore damaged muscle.

No kidding. They don't see women 6 months down the line unable to control their bowels. I wouldn't mind if they admitted they didn't know, I just feel as if they assume a knowledge and competence that they clearly do not have.

I had an episotomy and 3rd degree tear with DD through forceps, vontouse and her coming out Superman style!

Im now 33 weeks with DC2 and no one has ever mentioned about a ELCS.- Should they have?

Everything seems to be ok since and although never quite the same, ive not really noticed any damage since the birth (so far anyway!

Ive read a few things lately about tears and the option for ELCS. Not saying id automatically choose one but am now wondering if its something that should of been discussed with me or not?

Pigleychez I feel I am in a situation similar to you.

I had a 3rd degree tear with dd, repaired in theatre. haven't really had any problems since and no-one has mentioned a ELCS.

I am now 38+1 with dc2 and planning a v-birth.

I had not even heard about pelvic floor problems post-menopause.

I too am now wondering whether it is something I should have researched more, but had just assumed consultant obstetrician would have mentioned it if a ELCS was possibly advisable.

Mummee and Pigleychez, in the US after a 3rd degree tear an elc would be offered automatically but in the UK it isn't (see the stats I put in my post below) since it's believed 2nd deliveries are easier, as indeed mine certainly was. The issue is putting further strain on already damaged muscle, which may or may not happen, and is something that might not reveal itself until post-menopause.

The "magic words" to be offered an elective are "bowel incontinence" which can be actual (either before or during pg), urge incontinence, inability to control wind, damage to sphincter etc.

I had a 3rd degree tear as a result of forceps with my first baby, and although I didn't have incontinence, I do have fecal urgency as a result (sorry if too much info). I wasn't even given the option of a c-section for my second birth - I was just lectured on how vaginal births are safer. If I had a third baby I would insist on a c-section as things are definitely not nearly what they were before DD1.

It is really hard to balance the risks to health of baby and mum but for me a constant theme has been short term v.long term thinking.

A lot of studies I saw were just checking women a few months after birth and not following up enough post menopause - which for some of us could be at around 40-45.

My other musing was on what was repairable and what muscles/nerves often failed repair attempts. My bladder nerves and sensation did not work at all after DD's birth - no control and no sensation of needing to pee, just total leaks when changing from sitting to standing or getting out of bed - gravity peeing as I thought of it! Time brought back some control and some feeling but it isn't as it was.

I feel I gave natural vaginal birth everything I could to succeed first time round (no epidural just G&A, active before and in labour, birthing ball not sofa for position for months, cushion in car to tilt pelvis etc etc) - it failed because DD could not turn to a birthable position.

I'd love to feel all womanly and proud and deliver my child by myself, but at the end of the day I want to parent without having more disabling incontinence than my current inconveniences. Some people feel differently and I can understand that they want to take the risk or measure it differently.

When I read up and weighed it all my gut feeling was elective - for those who haven't had it discussed maybe get an appointment asap with your consultant, read up and take in a list of questions?

Thank you all so much for your posts. My previous 3rd degree tear was due to a failure to progress (after 5 days of labouring on my own, doing everything you're supposed to do!), eventual augmentation, epidural and forceps. By the time I had these interventions there was no alternative as I was exhausted and there was meconium in the waters, so I know that planning to refuse any intervention this time would be unrealistic if the worst happened again. I was actually incredibly lucky and got away without any significant long term problems. I did have intermittent feelings of prolapse and bladder weakness for the first year, but then things generally seemed to clear up pretty well (although of course who knows what the future holds). A recurrent problem for me in reaching a decision is the absolute refusal of all health professionals I've seen (including my consultant) to advise me either way! I understand their position in that the balance of evidence for and against both options are very finely balanced, but it still makes it difficult when any question is met with a shrug and 'it will probably be better second time'. Still, at least they've left it up to me. The only person who's come close to advising me is the physio who treated me following the tear, who basically said to count myself lucky that I got away with it the first time and not to push my luck with a second vaginal delivery!

So like most of you, I've had to base my decision on researching the medical literature for myself. There are so many facets to this issue that it's hard to keep all the different threads in your mind long-term, so your posts have really helped to remind me that the main issue is short-term vs long-term problems. Now that the section is looming it's easy to focus on the short term inconvenience and discomfort, especially as a number of friends have recently given birth to their second children easy as shelling peas! The temptation of hoping for an easy 2nd birth is so seductive. But I now remember that I previously decided that a section would probably be the best protection for my long-term health, regardless of how well the birth seems to go at the time. And I am also terrified of it going badly again and being left with some kind of disability while having to look after a newborn and toddler. Lovethesea, I agree that so much of the evidence base is far too short term. In fact I remember reading that the comparable bladder weakness statistics for v birth and c section were based on 3 months post-birth, whereas they should really be looking far further ahead than that.

It is so difficult, but your contributions have helped to clarify things for me again. Good luck to all of you, and with the decisions you make.

Glad it's helped a bit ealey - even now with my mind all made up I still have 'Oh what if it went so well this time .....' thoughts and daydreams. I see people up and about after a birth and am envious! My forceps birth kept me in hospital for 6 days and I hated being there.

My only grounding is - last time I did all they said to make birth go well and it went pear shaped in a big way and DD was in major distress. This time I am too busy and tired running after DD to do all the right things (exercise, birth ball not sofa etc etc) so what are the chances of it going swimmingly?

I just don't have the energy to be the perfect position pregnant person this time - I am slouching about to rest when I can and perfectly happy for bean to settle himself however he fancies.

With expecting a boy this time he'll probably be a little bigger than DD so I figure he's as likely to wedge himself in nice and tightly sideways as she did anyway.

I was also aghast at some of the studies - at 3 months I was on huge tena pads, limiting my liquids to the daily recommended amount and having major urge incontinence. A vaginal birth story they don't seem to talk of much.

I had a 3rd degree tear after dc1. Labour was extremely fast - only 2 hrs from start to finish, and there was no control when ds came out.

I also had a 3rd degree tear after dc2. This time labour was much more controlled and I breathed ds out and didn't push once ( he was a home birth).

With dc3 the choice was mine whether to have a cs or not. The consultant actually suggested a cs but not because of my previous tears,but because of the speed of my labours (dc2's labour lasted 25 minutes from start to finish)

i am so so glad I had a cs. I have been left with symptoms from the previous 2 tears which would have no doubt gotten worse had I had another VB. I was shocked however how no MW or Dr ever mentioned my tears again and never enquired about any symptoms.

Recovering from a CS is hard work,but it was a lot less painful than recovering from another tear

hi. I had a third degree tear with my first labour and went on to have a homebirth with my second. I was warned that I might have a similar tear and be rushed to hospital to have it sorted, but still felt it was preferable to try at home. I saw two consultants first who had absolutely opposing opinions on whether it was a good idea or not. I had daughter number 2 in water, and only tore second degree, which I was very happy about because I got to stay at home afterwards. Tricky choice, I found it almost impossible to know what to do at the time, but know I did make the right decision (hindsight is a wonderful thing). Good luck

I had an epi and 3rd degree tear with ds1 and was horrified by the thought of recovering from a c section and caring for a toddler when I was pregnant with ds2. After lots of research and chats with the consultant I decided that I would have ds2 in the midwife led unit and try for a waterbirth. In the end I didn't get into the pool as he arrived before it filled but I had a fab (student) midwife who did a very slow controlled delivery and I delivered the head fine but the little monkey caught me with his shoulder and I needed a couple of stitches partly to repair some of the mess from ds1's birth. So all in all it couldn't have been better! Also on the plus side the bumpy scar tissue from ds1 kind of stretched when ds2 was born and now is much flatter!

Thanks for your recent posts. I guess the good thing is that whatever you decide, there don't seem to be many regrets here. It's reassuring to see that lots of you have had better experiences second time around. Although I'm planning on scheduling the section, I'm not as terrified as I was about another natural birth, should things kick off early and quickly!

Well it appears that all the time and effort I put into researching this and making a decision has been a big waste of time. After over 2 years of being assured that I would be able to choose between v birth and c section next time around (the only basis on which I would consider another pregnancy), I just saw the consultant at 35 weeks who said that they're probably about to withdraw patient choice and that I will probably have to go through another vaginal birth (unless my baby stays in it's currently awkward position). I can't believe that they've pulled the rug out from under my feet at the 11th hour like this, and that after all this time and agonising I never really had a choice anyway. I hope the rest of you still have the freedom to exercise some kind of choice.

I would immediately complain to the NHS board about this change of plan being applied to women like yourself who got pregnant on the understanding of choice.

It is totally unacceptable that they would remove your option for an elective after damage that many consultants and surgeons believe is best dealt with by an elective next time round.

Have you had any support from psychology or from your GP post the last birth? Could you get something to show how you were affected and any letters they wrote to say you could choose this time and forward copies of those with your complaint?

I understand that the NHS has to budget and plan costs, but an elective while costly is no more so than years of physio, scans, tests, repair surgery, counselling etc from a bad vaginal birth leading to double incontinence - especially to someone who has chosen the other route.

Very angry on your behalf and nervous that my hospital will try the same - I will fight them tooth and nail if they do.

The truth is I've had precious little support or advice from anyone since the last birth, and nothing at all in writing. The hospital, my physio, my midwife and my previous consultant all verbally said that the choice would be mine this time around, but I have nothing to show anyone in evidence which is probably naive of me. I just feel in shock at the moment, and I'll remain in limbo until my next appointment at 38 weeks. If at that point I'm forced to go through another vaginal delivery then I'll certainly kick up a stink and complain, but it will probably be too late to do anything about it, especially as I went into labour just after 39 weeks last time. I'm sorry if I've worried you lovethesea, I'm sure you have nothing to worry about. I'm just very unlucky in a) the timing of all this and b) the lack of care and support I've had all along. I'm very angry because I swore I would never put myself in the NHS' hands again after my last baby, and now I have and they've let me down again. Ironically I now just have to hope that my baby will stay in a transverse lie, which feels really wrong as you should never have to hope for a complication.

Hopefully s/he is nice and comfy and not planning on moving at all! I also fancy a breech baby this time just to confirm my choice as logical for me.

My consultant has referred me to the psychology dept in the maternity unit due to my struggle to let go of the traumatic memories of DD's birth - she thinks I am at risk of ante or post natal depression because of it. With that in mind I am sure they would let me have my elective - or an awful lot of people are going to be sobbed on again