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Vaginal Birth after 4th Degree Tear?

post #1 of 154
Thread Starter 
Hiya all! I'm new here, so I don't know if this has been discussed, but I'm hoping there are others who have faced the same situation and can give advice/opinions.

Background: I had my first child in October. During my pregnancy, I read everything I could about natural childbirth, took Bradley method classes, even switched from a large hospital/OB to a small hospital/MW where waterbirth was an option. I was totally committed to a drug-free, intervention-free birth, and really felt educated about making that happen.

My labour was good; water broke at 3 am, arrived at the hospital (40 minute drive) at 7:30, fully dialated by 9:00 am. I laboured in the shower and pool and didn't even think of asking for drugs.

When it came time to push (ie, I was 10 cm and feeling a *slight* urge), I tried pushing in the pool, but found I couldn't get a good grip with my feet, so I got out. I squatted pretty much from the get go, leaning into my husband for support. My labia got really swollen right away. I'd only been pushing for about 30 minutes when the MW started to say "Here's the head" and "one more push". The MW had her finger in my vagina most of the time while I pushed. At the time, it seemed like this "helped" me push, but maybe it contributed to the swelling?

Anyway, I pushed and pushed and pushed. Eventually I got tired, and had to move to different positions other than squatting. I tried sidelying and semi-reclined, but not hands and knees (which I just didn't think of at the time). I'd periodically go back to squatting, but I just couldn't keep it up for more than a couple contrax.

At some point, I started tearing. The tear was in my vagina, not in my perineum, though. Around the 2.5 hour mark, they called the backup doctor. She tried to use the vaccuum but it wouldn't stay on. By this time my perineum was tearing, too. She then used forceps and had to try several times to get them positioned. I felt like I was being split in two!! She did a small episiotomy to try to "direct" the tears that were already happening, but it didn't work and I tore into my anus.

Anyway, baby was born healthy at 12:30 pm, after 3.5 hours of pushing. She was 7 lbs 14 ounces. So not too big, really. Oh, and I did go drug-free... Yeeouch! Forceps were meant to go hand in hand with strong drugs!! :

I had to be transported to another hospital and put under for surgery to have my pelvic floor repaired. The surgery was successful, and I don't have any long lasting effects from the damage. Sex is more or less normal, and I have normal bowel control, bladder control, etc.

The dr who did the repair surgery is recommending a c-section for any subsequent births. He is worried that further damage may not repair as well... that is, just because I've been "lucky" this time, if I tore badly again, I might have long term problems. He does concede that my next birth could go very differently and I might not tear at all.

Sorry for the long recap.... Finally getting to my questions!

If you were in my situation, would you try for a v-birth again, or schedule a section?
If you do recommend trying a v-birth again, what can I do to reduce the swelling in my labia/vaginal canal? Both my MW and I really feel it was a problem of my soft tissue not expanding normally to allow the baby to pass through; instead, I got so swollen, the birth canal was very narrow.
Are there any dietary measures I can take to increase the elasticity of my skin?
Do you think that the midwife's "help" with her fingers during pushing might have contributed to the problem?
I've heard about "labouring down"... do you think that is something I should try next time?
Agh! I have so many questions and so much anxiety about future births, and I'm not even pregnant yet! I guess I just want to hear from other mamas who have torn badly... what did you do for future births?

Thanks in advance!

Proud mama to Faith Olivia, born Oct 4, 2004
post #2 of 154
I've attended several births after previous 4th degree tears and have never had a repeat. I've had more than one mom birth a larger baby the second time around with no or minor tearing. I think personally I'd take my chances rather than schedule a c-birth.
I'd definitely discuss with my provider leaving the perineum alone entirely during pushing. I do think that perineal massage or frequent exams during pushing encourages swelling and tearing. There are studies that suggest that perineal massage encourages tears, as does the use of lubricants. I used to think perineal massage was helpful. The more reading I've done, the less I do during second stage, and the fewer tears I see. And I almost never see that extreme swelling in someone who hasn't had any exams during second stage.
The best way to avoid tearing is to push only when your body tells you to, in a position you feel comfortable in, and to keep all fingers out of your vagina. Laboring until the head is on the pelvic floor and the urge to push is irrestible is also good.
If you are not certain what to do, you could also, always reserve the right to proceed to cesarean if you feel things aren't going well. Most likely, your second babe is likely to come out faster (not always, but playing the odds, most likely) If you reached a point where it was felt operative vaginal delivery was needed, or if severe swelling and spontaneous little tears were seen again, you could always choose then to have a cesarean. If all goes well and pushing goes quickly, you can give birth vaginally as planned. This of course leaves the uncertainty up to the last minute, but at least then you may feel more like you made the choice based on what WAS happening instead of what COULD happen.
post #3 of 154
I had a 4th degree last time & am about to deliver vaginally soon. I didn't have the same issues (mine was caused by an extension of an epis). But, I wonder if you could also (in addition to the above suggestions) try pushing an a side lying type position instead of the squatting. My tought being that perhaps the blood pooled in the perineum due to the squatting then couldn't escape. I'm no expert, but just seems possible to me.

Good luck!!
post #4 of 154
i had a horrible 4th degree tear with my first. i tore all the way to my anus as well as tearing inside. the OB who sewed me up did a great job, though, and i've also had no problems.

i'm not certain what caused me to tear. i think my mw did everything she could, but stuff like that happens sometimes.

that said, i'll be giving birth to dd#2 any day now, and, hopefully, it'll be another vaginal delivery. i've been scared about tearing again. and i am concerned that when pushing time comes i might freeze up due to the fear. the recovery last time was awful.

i've discussed it with my doctor and she is supportive of me pushing in any position i feel most comfortable. says that's my body's way of preventing injury. she also suggested laboring down, like you mentioned. she even told me to put it in my birth plan in case she's not there when i get to 10cm.

this question on the "ask the experts" section of mothering.com is what started my research into tearing and ways to prevent it http://www.mothering.com/sections/ex...hive.html#tear

i agree with doctorjen, don't get a c-section because of what might happen. lots of things might happen. i know the fear is real because i feel it, but i don't believe it's in my best interest to give into it.

if you remember or even want to, pm me in a couple of weeks and i'll let you know how this birth goes. i know that hearing success stories from some other women has helped me be less fearful. hopefully, i'll have a success story to share with you!
post #5 of 154
If you felt a *slight* urge and your body wasn't bearing down then you probably weren't ready to start actively pushing yourself. I have heard many women say that at around 10cm there was only a slight urge or no urge to push and that their bodies got a 'break' of a sorts before they really felt the pushing urge.

Your MW should NOT OF HAD HER FINGER INSIDE YOUR VAGINA!!! That just plain interferes with your body's birthing flow.

If you had a drug-free labour, you should not of needed 'assistance' to push and if you needed that assistance, then it all seems to point to the strong possibility that your body was not ready to push/birth the baby just yet.

Forced/active pushing from the mother as opposed to your uterus pushing the baby out is one of the things that contribute to tearing. Yes, sometimes tears just happen but personally I have never heard of something as extensive as a 4th degree tear in a woman birthing unhindered.

Btw staying on your hands/knees until your body starts bearing down (your body, not you) will keep pressure off your vagina/perineum. When you feel the need to change position into a more upright position, try leaning forward against something, still on your knees. Your body will really let you know when its time for the rest to happen.

As for feeling that your tissues werent expanding 'normally' that could have had something to do with your baby's position or your birthing position. Maybe pressure was exerted on the tissues too early, before they had a chance to gently stretch/expand from the babys head on your cervix. Just because your 10cm doesn't mean you're ready to push, or your baby ready to move down into the vagina!
post #6 of 154
About 95% of 4th degree tears are from episiotomies that have torn too far. Pushing when YOU feel the urge, not pushing when someone else tells you to, and breathing the baby down will all help. Have everyone stay quiet with no counting. Take your time and avoid perineal massage, which can just swell the tissues that are already so delicate. Perineal support is good though! When you are crowning, don't push!! Just pant, or grunt slowly. It is OK to lose a contraction on the crown. It hurts, but it gives your perineum a chance to stretch out around the baby. I was just at a birth where the mother tore to a 3rd degree last time and this time the baby had a hand up there by his face, but she was slow, she had total quiet, and she barely pushed when the baby crowned and she came away with a perfectly intact perineum!! Good luck and happy (barely) pushing!

post #7 of 154
Originally Posted by Heather R
If you were in my situation, would you try for a v-birth again, or schedule a section?
I'd definitely have a vaginal birth. I had a bad third degree that included surgery for a repair at 16 months postpartum. I would never hesitate to birth vaginally again.

If you do recommend trying a v-birth again, what can I do to reduce the swelling in my labia/vaginal canal? Both my MW and I really feel it was a problem of my soft tissue not expanding normally to allow the baby to pass through; instead, I got so swollen, the birth canal was very narrow.
Are there any dietary measures I can take to increase the elasticity of my skin?
I don't think that it was a problem with your soft tissues necessarily. Did you do forced pushing? Were you pushing as you needed to or as your body directed you to?

Do you think that the midwife's "help" with her fingers during pushing might have contributed to the problem?

I've heard about "labouring down"... do you think that is something I should try next time?
I say, push when you want to, as long as you want/need to. Don't let anyone tell you that just because you're complete that you need to push. Your body will do the majority of the work - just get behind it when it's uncontrollable.

It sounds like you were given a specific "time limit" for your pushing.

Here's an article I recently wrote on this topic: http://www.midwifemama.com/honoring.html
post #8 of 154
With my 1st, I had an (completely unnecessary) episiotomy that resulted in a tear into my rectum.

I've gone on to have 2 other births with very minimal tearing. In my experience, there's not a reason to schedule a cesearean birth for a previous 4th degree tear.

Good luck to you.
post #9 of 154
I would push when the urge is irrestable! My body (I had nothing to do with or no option either) started pushing when I was only 8 cm. I had absoluely no control over it. And it was really rough, violent pushing too. (prosterior baby) I was on my back because I was paralyzed with PAIN. I couldn't even THINK to move to another position. I eventually sat up a bit. I only tore a teeny tiny bit on my perinium.

No fingers inside you either. Your body KNOWS how to push...you don't need anyone to "help" you. I think next time if you can birth in the water that might help too.

I would definately not schedule another c/s. How DARE he even suggest that? Has he ever given birth? Nope.....what does he know?
post #10 of 154
I hear "laboring down" used most commonly to refer to a mom with an epidural -- they turn the epi down and allow mom to "labor down," which brings baby closer to the perineum versus having her push because she's "at 10!" This encourages mom to push when she really has a feeling to.

I am assuming laboring down without an epi would be allowing your body to wait until you get the cues that it is unmistakably time to push. Many peeple don't realize there can be a resting phase, sometimes quite long, once a women is complete. Practitioners are so dang anxious to get the baby out that once a woman hits 10 they start directing the purple pushing. I firmly believe pushing time is cut down greatly if everyone waits until mom wants to push, until she can't NOT push, and then she is working in combined effort with her body and not trying to do it all on her own because she is being screamed at, lol.

I had a 3rd degree tear, and luckily, the thought never entered my mind while pregnant the next time, that I would tear like that again. I knew I had a horrible OB first time around and I figured with my loving midwives who cared so much for me, it would not be an option...and it wasn't!

Wishing you peaceful vibes, mama!

post #11 of 154
Thread Starter 
Wow! Thanks for all the replies!

I'm glad to hear that there is still hope for a vaginal birth, although considering where I'm posting, I'd have been shocked to hear otherwise! :

I'm surprised that you mostly agree that perineal massage could have had a negative impact on my pushing... well, not that surprised, really, because I feel the same way - but surprised that my MW did it if it was problematic. Though this was in a hospital, this MW is also a homebirth MW who has been attending births for 15+ years and is very well known/respected in the "birthing circles" in my city. I guess I just trusted her to guide me a little more than she did. When I interviewed her, she said less than 10 mamas had had episiotomies in her 15 years experience...

I know next time I will do two things differently: I will hire a doula. I have one in mind that does a lot of VBAC births... I figure she will have lots of tricks to help me avoid a c-birth. Also, I will bring a mirror. Can you believe they couldn't find me a mirror to see myself pushing?! Jeez, in the 3+ hours I was pushing, DH could have ran to Walmart and BOUGHT a mirror! Anyways, I think that would have helped me push effectively.

Pamamidwife: I wasn't given a time limit, per se, but I was just so tired and wasn't pushing effectively anymore. Plus, at that point, I thought I wanted the dr... I trusted that the mw wouldn't call her unless she was really needed...

Aprildawn: I'll try to remember to pm you in a few weeks and see how things went! Good luck!

I do think I started pushing prematurely, in retrospect. Right from the time I was admitted, the nurse kept asking, "Do you need to push? Do you feel like you're going to have a bm?" I said no at first, but then as labour progressed, I think I just let her "pester" me into pushing! They checked me, and I was 10, so they said, push! And the thing was, I "knew" not to start pushing too soon, but when you're in labour, and you know it's not going to end until the baby is out : it's hard not to push when told!

Anyway, I'm glad I posted, because you guys told me what I already knew... that I need to at least try to have a natural birth again... otherwise the what-ifs will really haunt me!

I'm sure once I'm actually pregnant, I'll be on here again to seek advice and encouragement.

Thanks so much!
post #12 of 154
Heather in fairness to your midwife perineal massage is a somewhat hotly debated topic. Some practioners swear by it while others feel it does harm. I haven't seen any studies that prove that it helps or hurts. I've had epis all three times so I have no insight into tearing but I did want to just chime in on that aspect of your question. My DD was my third birth but first non-drugged birth and I also feel that not waiting until I had the urge to push caused us some problems. I will definitely be waiting until I can't help but push this time. I hope you have a smoother birth this time.
post #13 of 154
Thread Starter 
Originally Posted by pamamidwife
Here's an article I recently wrote on this topic: http://www.midwifemama.com/honoring.html
Pam, what an amazing article! I actually got teary reading it, because it's as if you wrote in response to my exact experience! I will definately save it to read again. I wish you could be my midwife!

post #14 of 154
I tore into the rectum with my first. It was a very standard hospital birth (minus the drugs). My doctor took her time and repaired it well, and while it took quite a while to heal, it hasn't caused me any problems since.

I had a pretty bad second-degree tear with my second, another hospital birth. His head was fairly large (he was a full pound heavier and cm larger head circumference than his sister) and he came out very, very quickly, and I didn't know to hold back.

No tearing at all with my third, a home waterbirth. The water had a bit to do with it but I'm convinced that the critical factors were:

1) my midwife kept out of the area

2) I felt free to feel down there and support and move tissues as she came out
post #15 of 154
I tore badly with my first. It was pretty nasty. We lost count as to how many stiches it took. Basically, I was laid open from the inside out moving up to my clitoris. It ended there. I knew when I tore....I wanted to push, knew deep down that I shouldn't, but let my desire take hold.

Nothing hurt more than those shots of xylocaine at the base of my clitoris! Healing was long and hard. Even 4 years later, the spot right at my clit would open on occassion. I don't fault the person who did the stiches. I watched with a mirror and it was a dirty job getting it all fit back together. I think she basically pulled things to bit too tight.

I was just sure that I'd tear the second time around. I mean birth one was slow and easy and I tore like crazy and was left with a wound that would open after 4 years with normal sex.

Well, my daughter quite literally fell out < birthstory here (http://www.albegar.com) > and not even a skid mark! The stretching of her birth even seemed to somehow 'cure' the issue with the old wound. I've not had any issues with it opening since her birth.
post #16 of 154
Originally Posted by UmmBnB
Well, my daughter quite literally fell out < birthstory here (http://www.albegar.com) > and not even a skid mark! The stretching of her birth even seemed to somehow 'cure' the issue with the old wound. I've not had any issues with it opening since her birth.
This was exactly the case with my 2nd birth. It seemed like it healed the issues I had with my previous scarring. Honestly, it made sex way better because I wasn't cringing in pain.

I guess for some, another birth can be physically healing.
post #17 of 154
I had a 2nd degree cut with my first baby, and was terrified that I would tear the old scar with my second baby. Not only did the scar hold, but I only tore a tiny bit to the side when her shoulder came out. No stiches required.

After the first birth I ws very tight and sore for a long time. After second birth, well let's just say I stretched out nicely.
post #18 of 154
Okay, please bear with me - I am new at this and somewhat overwhelmed by all the little icons and such... This thread caught my eye, as I have been wondering the same thing since ds was born 9 months ago. Several of you mentioned surgery to repair serious tearing, esp. tears that reached rectum. By any chance, did any of you have a fistula? From what I have been able to gather in my own research, that is what I have. Unfortunately, I have no insurance, so will have to wait to get a definitive answer. Anyway, back to the topic, I am so glad to hear all these positive posts. Though in the last couple hours of labor, and for the first few postpartum weeks I insisted I would never have another, I would be devestated by the thought of not being able to have another baby, and even disappointed by the thought of a c-section. I have to admit, much of it was my fault, as ds was very big (9lbs. 9 oz.) and I continued to refuse induction until the amnio fluid was low, then refused a c-section when one of the drs recommended it (not my own - he said it was unneccesary). I suppose if I had let them induce closer to my dd, ds would have been smaller and possibly prevented the tearing.
Heather - I hear you about feeling yourself "splitting apart". Although I had an epi, it had worn off considerably by the time he was finally born, and I remember thinking, "I know it was not supposed to feel like that!"

So, I apologize for intruding on this discussion, I just had to speak up - it was so good to hear from women who are able to deliver naturally after a bad tear! Thank you!!!
post #19 of 154
I had a 4th degree with my first and have had 3 vag births after that with no problems and I had bigger babies too.

Good luck!
Kim Ann
post #20 of 154
Erika I don't think you can know that if your son was smaller you wouldn't have torn. For that matter you certain don't know that an induction done earlier would have worked. You could have very well ended up with a c-section then. Two of my three were bigger than your son and I did have epis but they were moderate and I had no tearing. I don't think weight has that much to do with it there are just so many other factors and besides you can have a 9lb 9oz baby that actually pretty skinny. The head size and positioning would be more important when it comes to tearing. I have a friend whose baby weighed three lbs less than mine but his head was bigger than my babes. So don't beat yourself up thinking if only had let them intervene sooner. :
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