more tear/episiotomy q's

[muse]

My first was born at home with m/w's. Somehow because I made that choice I've trusted ever since that my midwives made all the "right" decisions, but since moving back to the Uk and talking to m/w's here they've raised a few q's about the birth, one of which was my tear.
I had a bad 3rd degree tear which was very close to being 4th degree, and had to be transferred to hospital for stitching. The OB did a great suturing job so besides discomfort for 6 weeks or so I have been fine ever since. Now I'm due in 10 weeks or so and my m/w's here are asking what I think "caused" the tear. I was thrown by the q at first because I felt it was unavoidable, the m/w's did massage etc and my DS just had a big head. But now I think about it I had no urge to push at all and was told when I had to because they were worried about his breathing. Also I gave birth in a semi-reclining position, which was far from what I'd ever envisioned and probably contributed to the tear. We did try a birthing stool but the m/w's felt semi-reclining was the only way he was going to come out. Maybe they were dead right but I can't remember why I never tried being on all fours or a supported squat or why I didn't get back in the birthing pool.

Anyway...So I have q's now about how I can avoid that again, if possible. And besides that the consultant I saw here said that in cases where a mother has a previous severe tear, if they see that she is starting to tear in the same spot again they will do a quick episiotomy in a different place to prevent the tear going further into a 4th degree one. In some ways that makes sense to me and in some ways scares me. To you knowledgeable mamas does that make sense? I'd like to ask my m/w specifically about this but want to go in knowledgeable and knowing what I want first.

[muse]

hmm, no responses?

well to update I asked my m/w's about this and was shocked to hear her say that their team probably only has to perform about one episiotomy a year! Such a totally different approach here in the UK. So I think I trust that if they do think they need to perform one, there is probably a sound medical reason.

Now to just focus on how NOT to tear in the first place...

[etoilech]

I wish I had some comcrete answers for you, but I don't and I am wondering the same thing. In my case I ended up with an episiotomy and I am worried about tearing where the episiotomy scar is.

I *do* think your position and the fact that you were told to push when you weren't ready may very well have contributed to your tear. It is very likely.

The midwife I am going to see this week says she also does episiotomy "once in a blue moon", but very very rarely. She couldn't even remember her last one. She's also British.

Olivia

[CarolynnMarilynn]

Hi there.

I am pondering your post. My first reaction is to say that what causes tearing is a babe who is coming quickly, tissue that is friable, or an extension of an episiotomy, particularly in the case of vacuum or forceps. I do think being on a birth stool increased tearing -- but it can be a great tool for those times when babe is taking some work to birth.

Third degree tears are just awful. The only one I have had in 150+ births was in a mum with 2 other kids where she had a 2nd degree tear both times (?scar tissue?) and it was as the head crowned very quickly and the shoulders came right behind and were largish. Other than the quick birth, it was totally normal birth in a position the mum chose herself. I felt awful and discussed it with other midwives to see if I contributed to it (or just plain caused it). I don't think I did, but now I really talk to women prenatally about how the perineum stretches and help them visualize helping their baby crown gently, with their hands there to guide them. I also give them lots of feedback at the time of crowning to help them birth the head gently (if appropriate and desired, of course).

I am a hands-poised kinda midwife, meaning rather than having my hands on the head with pressure and supporting the perineum actively, my hands are there (if the woman wants that and she doesn't want her hands of the hands of a loved one there instead) ready to help a woman slow down her ejection reflex to aid in preventing tears. My clients have an intact perineum more often than not. And, like your midwives, my epis rate is around 1% -- they are just not needed very often.

Unfortunately, if you are tearing along the same line again it is likely a right down the middle toward your rectum (midline). If your current care providers were to do an epis to 'save' your perineum and an extension, they would likely cut to the side on an angle away from the rectum (mediolateral). It means fewer extensions into a 3rd or 4th degree tear, but is is more painful to heal . It is a source of debate, but most British midwives favour the mediolateral, while most North Americans prefer the mediolateral).

I just share this to give you some food for thought. How do you think you could be best supported? I encourage you to do some visualizations of a calm, slow and gently second stage with your own hands guiding your little one's head oh so slowly, allowing your tissues to stretch and give around your baby's head.

Best wishes,

Carolynn

[muse]

Thanks for the responses, mamas.

Originally Posted by CarolynnMarilynn

How do you think you could be best supported? I encourage you to do some visualizations of a calm, slow and gently second stage with your own hands guiding your little one's head oh so slowly, allowing your tissues to stretch and give around your baby's head.

Carolynn, just this is a very helpful visualisation for me in itself. You know, I never really thought about that stage of birthing before DS, or it was very abstract. When it came to it I really had no idea what was going on and felt quite disconnected from it. I didn't want to feel the head at all and could sense the tension in the room around DS's breathing. There were a lot of people yelling, "Push!", when I look back on it. I remember feeling this intense burning pain and for some bizarre reason assuming my m/w had cut me open. When I brought it up later she was shocked, and said no way had she...but that was probably the tearing as he crowned and her hands were right there at that moment.

I guess it's helpful just to go through it all in my head and realise that it could be quite different. I'm going to have a doula there as well so I can do some birth preparation with her too, keeping all this in mind.

p.s. carolynn, my ds is also kai, and we've had trouble coming up with another name we like...now I see your second one's name and LOVE it! Do you know the meaning?