Do I need a scheduled Caesarian after a third degree tear?

scheduled Caesarian after third degree tear

 

A scheduled Caesarian after a third degree tear was not even on my radar.  Actually to be honest, the actual birth was barely on my radar yet. 19 and a bit weeks still feels like a long way away and I’m just over here trying to make it through each day, let alone thinking about labour and birth.

 

In my last post I mentioned I had a standard appointment with the hospital Obstetrician.  I’m just going through the regular public system this time, with shared GP care so this is just a standard appointment that all women are offered.

 

I expected the appointment was mostly going to be about my recent morphology scan, a quick doppler check and we’d be on our way.

 

So when she asked about my third degree tear that I had from Rory’s birth and whether I wanted to schedule a Caesarian (which she explained was a standard offer for all women who’ve had third degree tears) I kinda just stared at her.

 

Did I want to schedule a Caesarian? ummm what?  

 

I clearly did a terrible job at hiding my shock and confusion because she quickly started explaining that the second option was usually an episiotomy to control the injury rather than just tearing back along the scar line.

 

At this point I finally found my voice again to tell her that actually I’d had an episiotomy during my first birth and I found the recovery from that terrible. The third degree tear was like a scratch compared to the episiotomy.

 

She mentioned how further injuries along the same muscle can result in incontinence (both urine and fecal) and then went on to explain that I’ve got about a 6% chance of tearing again (will I ever be able to escape the statistics around birth and babies?).

 

She wrote some notes on my file and said I should make sure I have an experienced midwife and not a student who can apply counter pressure and slow down the birth to minimise any injuries.

 

Ummmm. Yes please.

 

I think I walked out of the appointment still in shock.  Suddenly my brain was imagining worst case scenarios where I tear massively again and end up incontinent.

 

I straight away sent a couple of texts off to good friends, mostly to reassure myself that my immediate NO to this idea was in fact the right choice.

 

One even spoke immediately to a couple of midwives that she works closely with who came back with this being an overly cautious obstetrician opinion and that just because I tore last time, doesn’t mean I will this time.  She reminded me that every birth is different and suggested maybe the tear was from Rory coming out in a strange position.

 

Which reminded me that he came out with both of his hands on either side of his head, so no surprises that I tore at all really.

 

I’ve been sitting on this post for almost a week now.  Honestly, this idea that I ‘should’ have a caesarian or episiotomy is something I’ve definitely got to do some work around before it’s go time.  It makes me feel nervous and little less confident in my ability to birth, which is definitely NOT a feeling I want to take in to birth at all. 

 

It has made me reflect on the birth experiences I’ve had, which I guess is a good thing. It probably is time that I started thinking about it.  I’ve also been doing a lot of reading on 3rd degree tears and ‘the management of subsequent births’ as all the medical journals like to call it.

 

The information I’ve found so far has been quite confusing.  One study by the German Society of Gynecology and Obstetrics said that:

 

The available data do not allow any recommendations as to the birth mode for future pregnancies. The patient should be informed that in a subsequent vaginal birth the risk for a renewed injury to the anal sphincter muscles can be, depending on the data source, non-existent  or up to 7-fold increased; however, more than 95 % of the women do not suffer from a further higher degree perineal tear.

 

That confusing little statement followed by…

 

An elective Caesarean section should be offered to all women who have previously suffered from 3rd/4th degree perineal tears, and especially to those patients with

  • persisting fecal incontinence,
  • reduced sphincter function or
  • suspected fetal macrosomia.

Also for vaginal births in patients with prior 3rd/4th degree perineal tears, an episiotomy should be used restrictively

 

Sorry, what?  If I read that right, they said the data was unclear (you either have a non-existent increased chance of re-tear or 7-fold) yet they go on to recommend that all women be offered a Caesarean.

 

Another study by The English National Health Service and published in BJOG, An International Journal of Obstetrics and Gynaecology says…

 

Women who have had a third- or fourth-degree perineal tear in their first birth can be advised that the chance of having a similar tear in the next birth is approximately 7 in 100.

 

Also this…

 

These risks of an elective caesarean section have to be weighed against the clinical, psychological, and social burden of anal incontinence. One could argue that the best approach for women with a previous tear is not to offer them an elective caesarean section but to improve delivery suite practice, for example by providing manual support of the perineum in the second stage of labour, which significantly reduces the rate of anal sphincter rupture.

 

Some of the most encouraging comments I found though came from the archives of UK Midwives and Consumers email list. In many cases these were midwives sharing their experience and knowledge of working with 3rd and 4th degree tears.

 

In my opinion the lady would be a fool to choose an elective LSCS without long and careful consideration. She may not even get a nick this time!!! Yet a LSCS will DEFINITELY cut her open with all its associated risks!!

Why did this happen the first time is always a good starting point……was she on her back? did she have an episiotomy? Both these increase the risk of third degree tears.

I have cared for women with this scenario and they need lots of psychological care but also the correct information. I do not believe there is any evidence to support the widely held view that they are more likely to tear or would be better off with episiotomies or LSCS.

Better that she labours gently and physiologically, is given the type of care that promotes belief in her body and when the time comes to get into a position she feels comfortable in…..for most women this is all fours and head down all fours will help with gentle stretching of the perineum. 

Virginia Independent Midwife

 

and this…

 

I am bemused by people suggesting elective CS as a way to prevent perineal damage. They are suggesting that you go for guaranteed severe lacerations on your abdomen, cutting through skin and muscle and increasing risks of all sorts of complications (see ‘risks of caesarean sections‘) – instead of having a chance of lacerations on your perineum. Swapping the possibility of one adverse outcome, for the certainty of another.

Did your obstetrician discuss any other ways of reducing the risks of a third degree tear, such as avoiding forceful pushing in the third stage, and trying to ‘breathe’ the baby out?

Angela Horn

 

I think that sums up my feelings pretty perfectly. Why would I say yes to the certainty of having my belly cut open for the 6% possibility that I might tear again.  

 

But that doesn’t mean I’m just going to hope for the best and go for it. I’m definitely going to be doing my research on how to support my body during birth to not tear (counter pressure and breathing rather than pushing). I’ve also been looking into perineal massage in the last few weeks before birth and also water birth as a possible way to slow things down.

 

Other than the fact that Rory came out with his hands by his head, it was also a very fast labour. Two hours from start to finish.  Looking back I think I was so in it and not wanting any interventions like my first birth, that I possibly could have slowed down the pushing stage a little. I’m hoping water birth might help me to do that.

 

So that’s where I’m at.  I’d love to hear your experience if you’d had 3rd or 4th degree tears. Have you had any babies after? How was the following birth? Give me all your advice! 😉

13 Responses to “Do I need a scheduled Caesarian after a third degree tear?

  • Lyn Locke
    5 years ago

    Hi Bettina Have you ever considered a private midwife. They can allow you to birth at home or in the hospital birthing suite and give you lots of options and wonderful care.

    • Bettina Rae
      5 years ago

      Thank you. Yes I had a private midwife with Rory and it was a great experience. I thought I could get away without it this time but might be reconsidering.

  • I love the wisdom of the comments by those midwives. The model of OB care tends to manage risk very conservatively, sometimes ignoring very simple things that can be done to promote physiological birth. Hands by the head and a fast birth, and lack of coaching to move slowly during pushing/ perineal support all probably combined to give you that nasty tear and it’s not likely to happen again that way, especially if you keep educating yourself and advocate for assistance during pushing this time! Your body is not broken and you are totally right to trust it!

    • Bettina Rae
      5 years ago

      Thank you so much for your vote of confidence. Educating myself is definitely what I’ll be doing over the next 19 weeks. xx

  • I will have to stop following you. You were *offered* a Caesarian. You have a choice. Nobody is forcing it on you, yet you take this opportunity to mad mouth elective caesarians? I feel totally humiliated – wow. This post is shaming people like me. I can only imagine what you would be saying to your friends if you knew my birth story. I’ve had friendswho had to fight for a Caesarian after shoulder distocias. A Caesarian is what some women want, and what others need. I think it’s great in your case that you have been offered one and that you have the power to say yes or to say no. Best of luck.

    • Bettina Rae
      5 years ago

      HI Jess. I’m very sorry that you felt shamed by my words. That was certainly not my intention at all. I do think a scheduled Caesarian is a very important decision to make because it is a major operation, and I do believe I’m lucky to be able to make the decision rather than just being told what to do, as some women are. I don’t believe I bad mouthed caesarians. My intention was just to show my shock at how quickly it was offered and the fear I felt surrounding the issue.

  • You will do what is right for you and the little soul at the time. It will all fall into place and be exactly how it is meant to be. You instinctively already know how this soul wishes to become earthbound. Your ability to birth has already been proven, your challenge is to silence the mind, feel, focus, and be present in the moment and stay Connected with your souls purpose by staying grounded and not allowing your energy to wander. Whatever the outcome of the delivery, ours bodies have the ability to heal themselves.

  • Hi Bettina, I realize this post is 4 years old but I found it while researching this same topic for myself. I would love to know what you ended up choosing and whether or not you are now happy with your decision. Thank you!

    • I had a natural birth and with the help of compression and coached pushing from my midwives had minimal tearing.

      • Hi Bettina,

        Did you have a water birth this time? I have to make the decision wether or not I want a vaginal delivery or c-section this time around, and my heart is set on vaginal but my brain is saying c-section in the case I tear badly (3b) again. I am very interested in your story and would love to hear more about your delivery since you had minimal tearing this time around!

        • I’ve never had a water birth no. I find I always want to ground with hands and knees and the water doesn’t appeal to me while I’m in labour. My midwives were amazing and used perineal support and coached breathing during the pushing stage to slow him down. This helped so much.

  • Angelika
    4 weeks ago

    Had 3rd degree tears and actual problems with defecation. The scars were infected few times – it was soo painful and took away the joy of having a baby.
    I couldn’t control my gases for few long weeks after labour and it was really humiliating. Due to all the infections I could not go back to my sexual activities until 9 months after labour.

    I would like to have the option to choose c section with another baby and I don’t actually see me going through the whole process again.

    I would prefer to have very deep scars on my abdominal rather than down there all the way to anal area.

    They are offering you the option but they don’t force anything on you and I believe everyone should have the choice.

    • I do agree with you that everyone should have the choice. This was just my experience and my reaction to being told this at the time. I understand why you would want to choose a c section after your experience.

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