Vaginal delivery after 4th degree tear - 4th pregnancy

[Mammamia33]

Hello Moms!

I have 3 boys...

first was posterior and I had a 3rd degree episiotomy, but I healed just fine.  

second was my biggest (I am 5 foot tall and petite)  - he was 8 lbs, 7 oz, and came out like butter - no tears!

third was born 2 months ago, and was posterior, and I had a fourth degree tear.

My recovery has been great, except I am dealing with issues of gas escaping out of my V, and gas just in general - so lovely. I am hoping....praying.... this will get better and possibly fix itself?!!!

I was examined at my post partum check up and was told I do not have a fistula (common cause of gas coming out of the V).  I was told I didn't have much "support" down there, but since she was a midwife, she couldn't expand on that. I have an appt. with my O.B. in a month to re-evaluate and I will have more answers then. She would probably advise me to have a repair surgery eventually if I can not address the issue with kegels. 

I suppose my husband and I are greedy :) because we want at least one more baby...in a few years. I do not want to elect for a c-section, but I do not want to risk destroying my pelvic floor muscles for life.

I want to know what the chances are of delivering another posterior baby, since I've already delivered 2.  And even if the baby is not posterior, will I run the risk of tearing badly in the same places again? I've read that tears re-occur where they naturally occurred before, or along the episiotomy line (which I've had both, but no issues in my second delivery after having an epi with first delivery).

I have been encouraged by the posts here by people who have had successful births after a 4th degree tear. I feel on some level that I'd be playing Russian Roulette, but I think there's risk no matter what!

I would appreciate any feedback, thank you!

[Mammamia33]

I wanted to add that my midwife couldn't go into detail about my options and prognosis mostly because she was not allowed to - she works in a group practice alongside OB's.  I didn't mean to make it sound that she couldn't share a medical opinion solely because she was a midwife...hope I cleared that up! :) I love my midwife, and my OB!

[limette]

I don't know what YOUR chances are, but I've had three posterior babies. The first was a c-section, second vaginal with 3rd degree tear and the third was forceps episiotomy (sp?) and another 3rd degree tear.

It's apparently rare to tear as badly as the first time but it's definitely on my mind as well.

[moonmama22]

I had a 4th degree tear with my son 6 years ago.  The Ob insisted I don't have a fistula, and then realized that yes, I do.  It is not normal for gas to come from there!  I chose not to have surgery, since it is very small (no solids come through), and there is not much success with surgeries for them.  I was very concerned, but really wanted to have another child, and so spoke to my Ob.  He did not see any reason for a c-section, and was very encouraging about having another vaginal birth.  My daughter was born in July, I tore again, but it was only a 2nd degree tear, and I healed just fine.  This is nothing to do with posterior babies, but in regards to tearing, there is not neccessarily a greater risk.

[Mammamia33]

Limette, I'm so so sorry to hear that! I can imagine what your births and recoveries have been like :(  Did your health care provider advise you one way or the other on what to do with subsequent births?

Moonmama22, that is encouraging to hear. In a few years we will want at least one more child, and my fear is that I'll have a posterior baby and tear badly again, or that maybe the baby won't even be posterior, but I will tear along the same tear lines again.  Still, I'd take a 2nd degree over the other kinds!

[purplerose]

I can't help with posterier baby experience but my first birth I had a 4th degree episiotomy +tear, and then I had my second baby almost 18 months later, she was a pound heavier and much larger head and I did not tear *at all*. I tore because of the episiotomy and vacuum, not the baby.

[wombatclay]

There's a thread "vaginal birth after 4th degree tear" around here somewhere... aha!  Here it is.

I had a 4th degree tear with dd2... dd1 was posterior/asynclitic/big and ended up being born via cesarean.  DD2 was a VBAC (yay!) but she developed shoulder dystocia (Gaskin didn't work, McRoberts didn't work) and the "reach in twist pull" that eventually got her free caused a 4th degree tear.  The recovery was loooooooong and hard, and I developed a mild pelvic organ prolapse (bladder and uterine prolapse).  I was really scared when I got pregnant again, but I found a midwife/OB team that was willing to work with me and I had a great second VBAC... just a small, 2nd degree tear along the old scar line.

That said, surgery is an option, especially if you've got serious quality of life issues going on.  However, most surgeons wont do the surgery if you think you might get pregnant again and many wont do the surgery if you're breastfeeding (because hormone levels affect tissue elasticity/healing, and future pregnancy changes can damage the corrections even if a cesarean is done).  So options sort of depend on what providers you have access to and how big of a QOL challenge you're facing.

I'm sorry you had a 4th degree tear, but congrats on your babe!  I hope you heal quickly!  (I put together a "healing from 4th degree tears" handout for my local birth community... if you'd like a copy just send me a PM)