? vaginal delivery after 4th degree laceration

[mamasunflwr]

Not pregnant again yet, but I'm starting my research early.... I delivered a beautiful baby boy 6 months ago - here is how it went down.... after 30 hours of natural, unmedicated labor it was finally time to push! Baby's heart rate went way down with each push (it was the cord) so my midwife gave me an episiotomy and called for md back up. I was able to push the baby out without additional asistance, but did completely tear - 4th degree laceration. A resident (teaching hospital) did my repair. A week later I was back in the hospital because of severe pain and pus coming from everywhere. 6 weeks later I was in the OR to take care of the perineal abcess (basically another wow-big epis./4th degree). When the ob opened me up, she saw that there was also a rectal/vaginal fistula (this was suspected). The abcess cleared, but unfortunately, the r/v fistula did not. I was referred to a colo-rectal surgeon. I now have anal discomfort and some fecal urgency, although it is improving somewhat, and the r/v fistula has gotten smaller. I am hopeful and prayerful that future surgery (flap surgery/perianal reconstruction) will not be necessary. Both the ob and the colo-rectal surgeon have stated casually "Oh, you should probably have a c-section next time." I haven't discussed this with the midwifery group, and I am currently looking for a new ob. So, I guess, my question is, if I heal well, is a future vaginal delivery really out of the question? Are women able to safely deliver vaginally after having 4th degree lacerations ? Any insight would be appreciated.

[1stimestar]

Strictly anecdotally here, I had a 4th degree episiotomy/tear with my first, in the hospital. With my second, I had no desire to go through that again and birthed my 9lb daughter at home. I had a small tear that didn't require stitching though she did use a bit of medical super glue. And my baby didn't rotate her shoulders all the way before coming on out either. Guess she was in a hurry. Get someone who will protect your perineum! Good luck.

[anne1006]

I was told the same thing. I had an OBGYN come stitch me up after ds birth with my regular physician, and he said no more vaginal deliveries. Later he said I could get an ultrasound from a colo-rectal guy, who said the same. Both of them had the reasoning that it was better because if I had another 4th degree tear I may have permanent damage and poop my pants forever. I started doing some research, and actually found a really good thread on this board, I don't know how to search for it on here though. I found tons of mamas, like 40 of them, that had 3-4th deg tears and did not retear past 1st degree the second time. I really don't think that the risk is worth getting the c/s.
My line of reasoning is>....... if I go with the c/s I will have a 100% chance of major surgery, and a chance of infection, complications with epidural (ie spinal headaches), painful recovery, etc...
If I have a vaginal delivery I have a higher risk of tearing (my midwife thinks I would probably tear along the episiotomy line if I tear, but it probably won't progress from there). If I do tear there is a chance it could be serious, and a small chance I would need surgery, and an even smaller chance that it wouldn't be repairable and I would poop my pants.......
I really think my odds are better with a vaginal delivery. I also read in "birthing from within" that you are 9 times less likely to tear with a homebirth or birthing center midwife, so that is the route I'm going!!! Don't let them scare you into a c/s.....just keep researching and find a provider that gives you confidence. And stay away from anyone who says you will need a bigger episiotomy! I dumped my doc and 2 midwives before finding the one I have now and felt good about this upcoming delivery. Now I don't even worry at all about it, whereas I used to have terrible nightmares. Good luck!

[MsBlack]

What I understand is that the risk of a repeat 3rd or 4th degree tear is higher, after having had one already. And with that risk, comes the risk that due to prior scarring, repair will be less likely to be as 'good'. So, the risk is of permanent damage to pelvic floor with urinary and/or fecal incontinence.

That said--I also say, Yes, the 'risk' is higher--statistically speaking--but the averages do not apply necessarily to you as an individual.

Before you conceive again, it is important to do all you can to promote great healing of your perineum/pelvic floor. To me, this means both pelvic floor exercises, and various other natural healing methods toward healing. You can definitely utilize that wound, and your healing of it, as a motivator toward better overall self-care, knowledge of your body, how it works and what most helps you, as a unique individual, to heal. Herbs and nutritional supplements to promote healing of tissues and prevent excessive scar tissue formation (scar tissue can be so rigid--doesn't want to stretch), visualization, homeopathy, reiki/healing touch...all of these things and others can help promote your most excellent healing, which will help you avoid a repeated 3rd/4th degree tear. Start exploring now.

And once you do conceive again, do find a care provider and place of birth that will be most helpful in helping you avoid episiotomy and tearing in the first place. These things do very much make a difference.

By the way, the single largest risk factor for 3rd and 4th degree tearing is---episiotomy. Perhaps if all you did was avoid episiotomy....

good luck and happy learning--

[SublimeBirthGirl]

Well, I don't really know what I'd do. A cesarean is automatic major surgery, while with vaginal birth there is a risk of problems but they're by no means guaranteed. I think I'd plan a homebirth where I had 100% control over 2nd stage.

Just out of curiosity, what were your baby's apgars?

[mamasunflwr]

apgars were 9 and 9 - he was perfectly healthy (evaluated by the nicu immediately after birth because of the signs of distress and + meconium)

[SublimeBirthGirl]

So the episiotomy was probably unnecessary, huh. I think I'd stay home.

[tankgirl73]

I had 4th degree tears with DS -- and yes, there was a (probably unnecessary) episiotomy.

I always felt that I wasn't "put back together right" and was worried about being able to deliver vaginally in the future, especially knowing that scar tissue doesn't stretch as well.

When i was expecting DD, I expressed my fears to my midwife. She checked me over and said that things were probably "different" than they before down there, but it was well-healed and I shouldn't have any problems from the scarring.

I did a ton of research. The pp's are right that epiosotomies CAUSE more tearing than they PREVENT.

Also: WATERBIRTH is the best way to prevent future tearing. The stats on vaginal deliveries after major tearing are phenomenal. Read "The Waterbirth Book" for detailed info.

I was planning a waterbirth for DD, at home. When my blood pressure shot up, we ended up being induced in hospital.

Here is the second important thing: SQUAT when you deliver. I was on my back and my side with DS and he got "stuck" halfway down. I squatted with DD (despite the nurses yelling at me to lie down "for the sake of my baby" arghh) and she came out in 3 easy pushes!

And I needed 3 tiny stitches that I never even felt. I was out of the hospital in time for lunch and we were out running errands that evening.

The really frustrating part about it though? After the nurses were yelling at me to lie down, when the ob finally came in she said it was my decision and okay to squat as long as I 'knew the risks'. She informed me the risks were 'increased risk of tearing'. Um, yeah, right. *sigh* So anyway, in the post-birth doctor's report, it says something like "patient delivered in squatting position after being informed of risk of tears. Patient suffered multiple tears which were repaired."

ARGHHHHHHHH

Anyway. So yeah, it's TOTALLY possible to deliver vaginally even after a mess like that. Look into waterbirth -- or at least labouring in water -- and remember to squat. And make sure you have a GOOD midwife who's not going to cut an episiotomy!!!

[AmieV]

I thought there could be an increased risk of tearing in the squatting position?? Not that what happened to you was right by any means, but I thought I had read that the pressure of the baby's head + gravity can be worse for tearing especially in a precipitous labor. I know I have read that pushing in the sidelying can be used to slow down the pushing phase in an attempt to avoid tears. And I am sure I read that in a non-mainstream birth
source, I think it was the Birth Partner or Heart and Hands.
anyone know?
good luck with your research. If you opt not to do a csection I would definitely, definitely recommend using a midwife with waterbirth if possible.

[Acacia]

My neighbor is heading in for a c-section on Dec 3rd because her doctor has convinced her that if she has a vaginal birth this time she will have a colostomy bag for the rest of her life...She had severe tearing apparently, but in looking at the birth: induction, labor for hours, epidural that numbed her entirely..even her chest, pushing on back...what do you expect? Anyway, this doc is on my hate list lol...I could possibly believe the colostomy bag explanation until I found out her due date is right around Christmas and the c-section is set for 37 weeks...sounds like a doc of convenience...sorry that was a tangent. I wonder what the risks are in comparison though...what are the chances of having a colostomy bag in comparison to death from a c-section? This momma also had trouble with milk coming in (2 weeks) yet this doc is still saying c-section at 37 weeks is the best thing for mom and baby. :

[CEG]

[QUOTE=tankgirl73;9796740]

The really frustrating part about it though? After the nurses were yelling at me to lie down, when the ob finally came in she said it was my decision and okay to squat as long as I 'knew the risks'. She informed me the risks were 'increased risk of tearing'. Um, yeah, right. *sigh* So anyway, in the post-birth doctor's report, it says something like "patient delivered in squatting position after being informed of risk of tears. Patient suffered multiple tears which were repaired."

ARGHHHHHHHH

QUOTE]

Actually there is an increased risk of tearing in a squatting position... but your doctor didn't quite GET it.

There IS an increased risk of first degree tearsin a squatting position, but there is a decreased risk of second degree and higher tears and of course an decreased risk of episiotomy.

So a woman might be more likely to suffer a first degree tear because she squatted but that is in place of the second, third, fourth degree tear or episiotomy she would have had on her back. Am I explaining this well?

Here's a link to a WHO info paper: http://www.who.int/reproductive-heal...apter4.en.html

Sounds like your doctor might have just skimmed that chapter in med school and not actually read the entire thing.

[wombatclay]

I had a 4th degree tear with dd2 (a vbac, labored in water, total freedom of movement/postition, amazing support but she had shoulder dystocia and I tore...her apgars were low but she is fine now). I don't have a fistula, but I do have a bladder prolapse and even now at 5.5mo my "under carriage" is pretty delicate and nowhere near healed. So this is something I'm debating as well. I've had a c/s and I've had a 4th degree tear and I don't know what I'll do next time round. It scares me silly honestly.

My OBs (wonderful amazing natural birth advocates) offered both sides when I asked. Basically the scar tissue isn't as stretchy and future tears may not heal as well. But they have attended several women who have had "catastrophic" tears in the past and don't tear again. They suggest doing everything possible to heal fully (diet, exercise, regular perineal massage starting now and going till the end of the second trimester then hands off for the 3rd trimester/birth, regular sitz baths, belly dance and other activities that will re-integrate the vaginal area into the whole body). They also told me to consider an epidural so that I'd be more "in control" in terms of letting my body do as much as possible without pushing (I had 4 hrs of overwhelming pushing contractions, my uterus and I were exhausted, then the dystocia hit) and so I wouldn't have the fear of pain in case of another tear holding me back from letting go.

They also suggested that the whole thing could wait until labor...that I could labor and have a provider keep an eye on things and that if I felt things were going wrong or if I was pushing for hours again and there was some question then I could decide to go to c/s. They also suggested that I could get an u/s around 39 or 40 weeks to measure the babe's head. Not weight, since u/s isn't good for that and fat squishes, but I have babes with big heads and now I have a history of dystocia so I have a fear of "big boned babes"...and a late u's could give me helpful info in terms of potential problems. For some reason that really helped me feel better...the thought that nothing is set in stone. I can plan for a vaginal birth but keep a surgical delivery as an option. I hope not to need that, I hope to be in the percentage of women who deliver vaginally with minimal additional tearing after a 4th degree. But I will be making peace with the thought that I can change my mind and that will be okay.

hugs mama, and I hope you find healing!