Risk factors for repeat 4th degree tear?

[Clover Honey]

Hello,

I have read through posts about repeat 3rd or 4th degree tears over the past couple of years - and while I have read many encouraging stories I am wondering what it is that is best for my particular situation.  Each time I read research pubs, it seems that I have many of the risk factors for increased chance of a repeat tear, but then there are such positive stories out there that I'm having trouble making a rational decision.  I am currently pregnant with my 3rd baby, and I will wait to make a decision until labor begins and I do have an extremely supportive birth team assembled.  I am just waiting on information such as what the scar tissue looks like during labor, what my PT thinks down the road, how large this baby is looking, etc.  (BTW, hopefully my marginal placenta previa will have moved enough by then as well...but that's a different story).

Here are my circumstances, please give me your opinion or any information you can share.

1st baby - cesarean, 9lbs, cascade of interventions

2nd baby - unmedicated VBAC, 9 lbs 4 oz, no interventions at all, MW, doula, pushed in all of the optimal positions, pushing lasted 3 hrs, 4th degree spontaneous tear

I am afraid of the following:  that I will be almost 38 yrs at delivery, that this baby will also be over 4000g, that my "short" perineum will contribute to another spontaneous tear (it is 2.5 cm long), that my original tear was spontaneous and there were no factors other than perhaps pushing too hard that I can change for the coming birth - and my biggest concern is that I currently experience urinary, gas and fecal incontinence and that a second tear/repair will worsen the anal sphincter.

It seems like I have many strikes against me.  I worked HARD for my VBAC, and believe in birth whole heartedly.  But until I experienced fecal incontinence (and it's only minor right now - but still, can you imagine?), I couldn't imagine my quality of personal/family life with this condition worsened.  However, this is my big chance to walk away from my 2nd vag birth unscarred and feeling victorious.  What a choice to have to make.

Thanks for reading!

[alyssacorinne]

I had a fourth degree tear with my first baby which resulted in a fistula and two subsequent repairs...all that's to say that I have some idea of what you went through and the decision you're facing now. My next birth will be a c-section, no question. After the trauma of my first birth, I feel very much at peace with that decision. That said, if I'd torn badly but healed up well, I would have considered another vaginal birth.

Given that you're already experiencing mild continence issues, I think it does make a lot of sense for you to have a c-section. Those issues are likely to get worse when you hit menopause so I think it is well worth keeping everything as strong and intact as possible.

If you do decide to have a c-section, I hope you can come to find some power in that decision. You should feel victorious no matter how your baby enter the world, and preserving your quality of life so you can be a strong mother is incredibly important. I hope this is helpful!

[giddiegoof]

I had a 4th degree tear that developed (or maybe was from the beginning, just not diagnosed) a fistula with fecal incontinence.  I was scheduled to have it repaired and discovered I was expecing my second child - no repair surgery at that point!  I found a homebirth midwife who delivered my baby in a waterbirth.  The fistula remained unchanged.  I had the repair surgery when he was 6 months old, and then about 22 months after, delivered my 3rd at home (came too fast to fill the tub!) and had only 1 stitch.  I will say though, that after surgery I had some discomfort with intimacy.  My naturopath recommended a homeopathic remedy to help with blood circulation (sorry to say I can't remember the name), which did help.  I also applied wheat germ oil vaginally in the region of the scar tissue during my 3rd pregnancy to help soften the tissue.  My practitioner believes wheat germ to be better than Vitamin E for scars.  I don't know if that will help your decision or not.  I strongly believe that the hospital staff's recommendation to me during my first child's birth caused the severe tear, and therefore it became very important to me to stay out of hospitals for my future births. 

I would advise you to pray, ask knowledgeable professionals (including midwives, for their opinions can differ vastly from conventional practitioners) for their opinions.  See if a naturopath in your area would know of anything to support your body and strengthen it prior to delivery.  My heart goes out to you!  It is such a hard decision.

[giddiegoof]

By the way, I hope I didn't sound anti-c-section.  I would say that my third birth was a healing experience for me, but for someone else a c-section may be more healing/comforting than feeling as though you had resigned yourself to incontinence.  I also forgot to mention that the surgeon who repaired my fistula advised me to have future babies by c-section, and reading many posts here from moms who delivered vaginally, post-surgery, inspired me to try the same.  It was a hard choice, because believe me - I hope I never have to repeat the fistula repair surgery. 

[Clover Honey]

Thank you very much for your reply.  I'm getting close to decision time; I'm now 33 weeks (and Previa is completely resolved).  It's still very much up in the air. I will say, that I would try another vbac no question if I could birth in water (since I am a vbac, even though it's my 2nd vaginal birth, none of the MWs I trust would be able to attend my HB.  Also, the one hospital that allows water birth has a vbac ban).  I can labor at my chosen hospital in the tub, but not birth.  So, that would be better than only laboring on land, etc.  I think there are more things I could try - one I'm very interested in is an asymmetrical position of my legs while pushing, so that the perineum is not already being stretched in two directions while birthing.  I plan on having DH and doula help me use a birthing peanut to support my leg(s) if needed, so that I can relax as much as possible,etc.

Honestly though, there is something else stopping me in my tracks.  DS (the vbac baby) has had low tone/developmental delays etc.  and now at almost 3 we're going through testing to see where he's at - and he has global delay that is very significant.  Since the birth, I have worried about him and he has been followed by feeding teams, Neuros, EI therapies, CST, Naturo, etc - the whole shabang.  We've been through a lot with him, and I'm wondering if between the fear of future incontinence and any possibility of risk to another baby from a hard birth - is any of that worth my preferred mode of birthing?  There are certainly risks with c-section, and they are serious and the outcome can be far worse.  So, I'm weighing it all still.  It's an impossible task and I almost wish my choice would be taken away so I wouldn't have to make what seems to be a grave decision either way.  I just want to enjoy the arrival of my last baby.  I would have the option of a gentle cesarean, and if baby is well then absolutely no separation from me, (or DH if I were shaking or had issues,etc.).  I also know that u/s size estimates are not reliable, but with a history of 2 9+ lb babies already, and this one on track for about 10 lbs., ... yikes.  

If baby ended up with CP/MR from delivery, or I had worsened fecal (and urinary) incontinence - I would slip into depression (who wouldn't?) and not be able to be the mother I want to be.  

Anyway, thank you for the opportunity to explore my concerns further!  I'm constantly debating myself!

[lbignr]

I am wondering how your second birth went.  Did you go for the c-section? 

[Clover Honey]

Thanks all for the responses, they're very helpful.  I'm 37 w 3 d today, and so far the plan is to go for a vaginal birth and change the plan according to any new info we may get (the changes might be to add a low dose epidural to relax the perineum or to move to a gentle cesarean where I or DH would get to do unlimited skin to skin with baby with no separation). 

I did have an u/s yesterday with a very experienced Peri and we got good pictures and repeated measurements and baby is on track to be 1 lb larger than my previous (which could also mean +/- 1 lb, so baby could be the same size).  That means at this point, if I go into labor before 40 w she'll be a manageable size (for me emotionally, you know?).  I'll go again at 39 w for another set of measurements and see if her rate of growth continued or slowed.

I have a team of two amazing Drs., and they are so incredibly supportive.  C-section is the last thing on their agenda, unless it looks like baby will be 10.5 - 11+ lbs then we would probably agree that I would feel better with the surgery.  I've also been seeing a PT for my pelvic floor and scar tissue, doing very gentle massage at home with olive oil.  They say my scar looks wonderful, very soft and well healed.

So, there's my thought process and what I'm thinking today is that I am a good candidate to try for another vaginal birth and that my Drs. and doula are knowledgable in helping me birth to a very calm manner, with no purple pushing, no laying or sitting on my backside, and understanding what I'm listening to while doing Hypnobabies.  I will also labor as long as I wish in the tub there, but I am not allowed to birth in there (which is hard for me to process, but we're working to get that changed.  it just won't happen in time for me).  I'll try to update about how things go.

Good luck to anyone else making this decision, it's been more difficult than I could have imagined even though I have ideal support for another VBAC.  Perhaps I feel a bit of pressure to try instead of requesting a RCS, but that's not really what I want in my heart.  I just want to find the balance between ensuring the safest and healthiest delivery for both myself and baby, and that's tricky this time!!

[Clover Honey]

Came back to update - another VBAC, only a small 2nd degree tear!!!  Baby was even larger.  Took lots of care and my time pushing, slowly and breathing deeply.  Paused through many contractions with no pushing and just let baby move down slowly until it was time to do the hard work.  Then was careful and slow, but still powerful pushes.  When head crowned (I made sure to use a large mirror so I could see exactly what to do), I stopped and let the stretching happen several times.  Listened to Hypnobabies Pushing Baby Out track on repeat with one earbud in and never took it out.  It was my best birth ever!

[Belia]

Congratulations, mama!  What a gut-wrenching process you had to go through to reach this point.  Many, many best wishes for a wonderful babymoon.

[delly12]

Hi

I also had a 3rd degree tear with my only child- luckily I have had no problems.

If I suceed in conceiving again I will opt for a c section. To me pregnancy is about having a child, not about the labour process. For me the least risky option is c section.

Good Luck!