Should I have an elective caesarean after third-degree tear?

[eastegg]

Calling all those who have faced or are facing subsequent babies after a bad tear the first time around. I've lurked on one or 2 threads and done a bit of internet research a while back when it was all a bit theoretical but now it's happening for real.

I'm 15 weeks, DS is nearly 2. He was born with forceps, I had an episiotomy but it turned into a 3(b) tear. I now have what class as 'symptoms' although I had none for at least the first year of DS' life. I'm talking more urgency, frequency and every now and then a bit of leakage of liquidy stuff (I'm talking poo, not wee, as anyone who's had this sort of tear will understand!) Sorry for the TMI by the way. It's nothing dramatic and it's only every now and then but I'm told I would be eligible for an ELCS if I wanted. Saw consultant midwife on Friday who told me that. She, along with other MWs I've spoken to, have been generally very positive about how much easier it often is 2nd time around. In fact I get the feeling nobody would be talking to me about CS if I wasn't raising it, although the RCOG guidelines (which CMW referred me to) say all women in my position should be counselled about and offered CS. They also say that on the available studies, which are admittedly scant, there's about a 20% chance of symptoms getting worse with a subsequent vaginal delivery.

I feel quite positive about CS anyway but obviously I'm aware it's not ideal. I feel there's sense of 'what if a vaginal birth all went absolutely brilliantly then I'd have an amazing sense of achievement' creeping into my thinking. I admit a tiny bit of me thinks I'm being a wuss and should just go for natural (and I hate that bit of me, as there's nothing wussy about a CS and we shouldn't be thinking in those terms anyway!)

Sorry for the length of this. Any experiences and advice please.

Hiya,
I am facing similar decisions, now 13wks preg with my 3rd. My first labour sounds just like yours - forceps, episiotomy, 3(c) tear. My 2nd labour was great, quick (just under 4 hours), no intervention, just gas & air, but yet another 3rd degree tear (3a).

I had dating scan last week and saw consultant about delivery options... like you, if I hadnt raised my concerns at booking, I think they would just be letting me get on with a normal vaginal delivery, Its only because I've raised my concerns about long term damage to down below that they're now discussing it with me. I dont have any 'symptoms' from the tears now, but apparently its later on in life that things can get 'messy' (if you know what I mean!!).

My consultant is happy to let me have a c-section (we also discussed it at the dating scan for my 2nd child, but it was decided I probably wouldnt tear again....hmmmm... and so I went for natural vaginal), and this time, the consultant pointed out that I am only a third of the way through my life, and the risk is, if I tore again badly, then I might have some degree of double incontinence for the rest of my life. It was at that point my husband declared he definetly wanted me to have c-sect (he was very anti it before, he's now very for it)!!

Anyway, to cut to the point... I am now going to have an endo-anal scan (Lush!) to look at the state of my sphincter muscle... if it looks like all is great and no bad scar tissue, then I may go with another vaginal. If it looks like the muscle is on the brink of giving up / looks in a bad condition, and that any future tear might totally ruin it, then I'm having a c-sect. It might be worth asking if you can have a similar scan? THey dont do the endo-anal scan in my hospital, so I have to travel further afield, but I'd like them to have a look at my bottom (however unpleasant it may be!) before I make a decision.

So, my advice is, perhaps see your gp or midwife and ask if they will arrange an endoanal scan for you, particularly given you are already experiencing symptoms from your previous tear...then you will probably be in a better position to decide which is the best way forward.

Good luck and hope all goes well for you - isnt pregnancy / childbirth so glamorous?!!! I love it all the same though!! x

Thanks so much for your reply. Sorry you've had a similar thing twice. There was a lot of mention of 'endo-anal' thingies in the RCOG guidelines. Have you read them? It's all quite interesting although the bit about future deliveries is short and backed up by not very much research. Still, it's interesting to see some stark statistics which funnily enough no midwife had mentioned...

Sounds like the scan is a good idea for you as you have no symptoms and the back-up of good news from the scan might be just enough to persuade you to go natural. However, as I've got the symptoms I've got, I thought when talking to the MW on Friday that no amount of examining me was really going to reassure me on the risk-to -my-sphincter side of things, and that really for me it's about weighing up all the other pros and cons of natural vs CS. So at the moment I haven't got any sort of examinations booked in, just an appointment with the obstetrician in June which would be a chat I think. I might change my mind about whether to be examined though. I suppose it might throw up something which would make me definitely want a CS!

Good luck with your decision and with the birth.

hiya just wanted to share my experience with you. i also had a bad 3rd degree tear and forceps with ds. this took a very long time to heal and i found it all very traumatic. however after discussions with the consultant decided to go for elcs this time. i had it 3 weeks ago and it was sooo much better than the awful 3 day labour and tear etc. i feel so much better this time round and have really been able to enjoy my new baby.

i think esp if you have had symptoms its not worth the incontinence risk trying vaginally again as you just cant guarantee what could happen. obv up to you but hope that helps

good luck!

Thanks yummy. I think I am leaning towards a CS anyway. But then I remember how well my first stage of labour went (got fully dilated in 7 hours and then it was another 5 before DS was born!) and think if I could just crack that pushing bit it could all be amazing. Then I think it's not about it being amazing, just as safe as possible.

Really glad your ELCS went well. I've heard lots of good stories about them and it is after all how I came into the world. I think I could almost look forward to one, although I appreciate it's a big deal.

I had a episiotomy and bad tear with my first delivery and the damage caused wasn't repaired properly so I had to have surgery to repair everything down there. No subsequent symptoms but the trauma of it all and my terror of going through it all again (kept crying at every mw a ppt when we started to discuss my history) meant that my mw was v supportive of an elective cs. It was fantastic for me, the recovery was so much easier than everything I went through with the first. I am now pg again and will have another elective cs. I just couldn't bear the risk of anything going wrong down there again and was happy to take the (relatively tiny for a planned cs) risk of the cs. You have to be happy with your decision but just wanted you to hear my story.

RCOG? Where can I find these guidelines? I am not pregnant at the moment, but would be very keen to have an elcs in the future following episiotomy breakdown and repair - have urgency etc too Eastegg.

Had those lovely scans you are talking about icravecheese last week - not as bad as I thought, though not the most pleasant way to spend a morning either! Have been told that I can have a CS if I have actual damage to my sphincter muscle, if not then I have to convince a consultant

Completely terrified by the thought of giving birth again tbh.

Thanks everybody this is helpful. Rufous sorry you feel so scared; I know what you mean. If you have urgency etc, then as far as I can tell you have symptoms that mean you should be offered an elcs. RCOG is the Royal College of Obstetricians and Gynaecologists - just type that in google and follow the links and you'll find all their guidelines. It's called something like 'Management of third and fourth degree tears'.

If you decided to give vaginal birth a go there are a few things you could do to minimise your risk of tearing again -- avoid an epidural (they lead to higher risk of instrumental delivery which usually requires an episiotomy), ask the MW to support your perineum with warm compresses when the head is close to being born, avoid pushing on your back (kneeling, squatting and side-lying are quite good) and/or consider giving birth in the water (water births have been shown to reduce incidences and severity of tears).

Oh wow, I'm going to check out the RCOG guidelines too... thanks for the tip.

Yes, I am SOooo not looking forward to my 'bottom' investigation!! I kind of wish I hadn't asked if there was anything else they could do to check whether my bottom muscles were ok... they would have happily given me a CS anyway. But hey ho, I'll expect a fun morning at the hospital... the more I think about it and read the above posts, the more I'm erring towards just asking for a CS, regardless of the outcome of the scan. Good luck ladies!