Hi! I'm a new doula and I am working with a mom who had a routine episiotomy with her first birth which then extended into a fourth degree tear. Seven months after her birth she had correctional surgery because the tear did not heal properly. She is pregnant again now, due in May, and was told by the surgeon who repaired the injury that she should plan a C-Sec the next time around. After talking with her new OB, who is supportive of natural and low/no-intervention birth, she has decided to plan a vaginal birth. Her doctor encouraged her to hire a doula and plan to labor and deliver in ways that support the perineum to help prevent another tear.

I have done extensive reading and attended a training course, but this will be my first birth. I'm aware of a few methods that will help prevent another tear--avoiding an episiotomy, water birth (not an option at this hospital), alternative birth positions, perineal support--but I could use some expert suggestions.

Thanks in advance for your help!

I have good news for your client. The key factor to avoiding another anal tear is to not have an episiotomy. To a lesser extent, giving birth spontaneously is also protective. I have two studies looking at anal sphincter injury rates at the next birth after having one at the first birth:

Martin S, Labrecque M, Marcoux S, et al. The association between perineal trauma and spontaneous perineal tears. J Fam Pract 2001;50(4):333-7.

Peleg D, Kennedy CM, Merrill D, et al. Risk of repetition of a severe perineal laceration. Obstet Gynecol 1999;93(6):1021-4.

Martin et al. found that only 1% of 1,900 women having no episiotomy at the second birth had a repeat anal tear. This was the case even though 18% of the group had a vacuum extraction and 2% had a forceps delivery. Peleg et al. found that 2% of 290 women giving birth by their own efforts and not having an episiotomy had a repeat anal injury. No women having instrumental deliveries and no episiotomy had an anal tear, but there were only 17 women in this group. Among women having an episiotomy and a spontaneous birth (n = 376) , the repeat anal tear rate rose to 11%, and it soared to 21% in women having both an episiotomy and an instrumental vaginal delivery (n = 56). A care provider who supports normal birth would surely refrain from episiotomy, but it wouldn't hurt to ask.

Other strategies to avoid a repeat anal injury based on the obstetric research would be:

• Avoid an epidural. Epidurals increase the need for instrumental vaginal delivery and episiotomy.
• Give birth in a position other than recumbent or semi-recumbent, in other words, upright, side-lying, or hands and knees. Women are more likely to have episiotomies and instrumental deliveries when they deliver on their backs.
• A recent study found that neither warm compresses nor perineal massage at the time of the birth reduced tears in women attended by expert midwives who performed an episiotomy less than 1% of the time, but easing the head out in between contractions did. If she likes the sensation, though, warm compresses may help your client relax the perineum.

Common sense says to keep the legs comfortably apart for the birth. If the perineum is already at full stretch because her legs are wide apart, the perineum will have nowhere to go. I can also tell you from experience that your client is likely to need extra reassurance at the time of the birth when she feels the burning sensation as the head comes through the vagina. Phrases such as "Let the baby come," "Ease the baby out," "Let go around the baby," or "Breathe the baby out," may prove helpful.

Anyone else have any suggestions?

-- Henci

I had an epidural and episiotomy with my first child and ended up with a bad 4th degree tear.  I haven't had any more kids yet but I was talking with my new dr and they said definately schedule a C-section for the next delivery. I have done extensive research on the topic on the internet and I've read the same suggestion.

There is a reason why they gave an episiotomy in the first place, to make the baby come out more quickly and easily (and usually it's at the Dr's convenience).  If you don't want to risk further damage then most definately schedule a C-section.   If I would have known that I would have gotten a tear I would have just skipped natural birth all together.  It's one thing to get fulfillment from delivering your child naturally, but the irreversable damage that it caused I still live with to this day and it's had a major effect on my physical, mental and emotional health. My daughter got stuck behind my pubic bone and the dr broke her collarbone just to get her out of me. Does that sound like a good way for her to have entered this world?  Vaginal birth is not worth it.

I am sorry you have had this difficult experience. It may, however, have been avoidable, and you may wish to know this because cesarean surgeries have their own potential harms for you, the baby, and all future pregnancies. For one thing, studies show that episiotomy neither prevents nor relieves shoulder dystocia (when the baby's head is born, but the shoulders hang up behind the pubic bone). There is, if you think about it, no reason why it should, seeing as shoulder dystocia is not a soft tissue problem. You may also be able to avoid repeating the shoulder dystocia by giving birth on your hands and knees.

Whatever you decide for your next birth, you say you have experienced mental and emotional distress as a result of your experience. You may want to know about Solace, a peer support website for women who have had a challenging birth experience.

-- Henci

Bruner JP, Drummond SB, Meenan AL, et al. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med 1998;43(5):439-43.

Dandolu V, Jain NJ, Hernandez E, et al. Shoulder dystocia at noninstrumental vaginal delivery. Am J Perinatol 2006;23(7):439-44.

Gurewitsch ED, Donithan M, Stallings SP, et al. Episiotomy versus fetal manipulation in managing severe shoulder dystocia: a comparison of outcomes. Am J Obstet Gynecol 2004;191(3):911-6.

Youssef R, Ramalingam U, Macleod M, et al. Cohort study of maternal and neonatal morbidity in relation to use of episiotomy at instrumental vaginal delivery. BJOG 2005;112(7):941-5.

I had a spontanteous fourth degree tear with no episiotomy with my first.  Apparently, it is very rare.  Unfotunately, there is no way they know you're going to tear like that until the baby's head is crowning and at that point, it is too late to do anything about it.  I am pregnant with number two now and due with him on 3/17/09 (35 weeks this Tuesday.)  I sitll have not decided on whether I will have the c/s or try it again vaginally.  The Ob practice I go to will support whatever I chose to do, but I can tell that they would probably chose the c/s for me if they could.  I still have a little time to decide, so we'll see.  A lot of women I've talked to were happy with their choice for the second timea round regardless of what it was, so I think one has to do what feels right for oneself.  You won't know if you made the right decision until it's been made and carried out.

I'd like to add that I didn't have vaccuum or forceps to assist with the delivery either.  In any case, I'm not upset with anyone about the outcome.  I healed up very well thankfully, which is why I am probably considering doing another vaginal delivery. 

If I may put in an oar, I would suggest you go for the vaginal birth. The deep tear is not likely to repeat. Among four studies I have on the issue, the repeat rate of anal injury ranged from 1% to 5% in women who had neither episiotomy nor instrumental vaginal delivery at the second birth. In other words, your odds are between 95 and 99 to 1 that you won't have a repeat. On the other hand, cesarean surgery poses a long list of excess risks to you and your baby and to any future babies as well. You will also be less likely to tear deeply if you give birth lying on your side or at the very least that you birth with your legs comfortably apart and not so far open that your perineum (the tissue between the vagina and the anus) is already at full stretch. Also, once the head is crowning, let the contraction do the work and breathe, rather than push, and ease the head out in between contractions.

-- Henci  

Dandolu V, Gaughan JP, Chatwani AJ, et al. Risk of recurrence of anal sphincter lacerations. Obstet Gynecol 2005;105(4):831-5.

Edwards H, Grotegut C, Harmanli OH, et al. Is severe perineal damage increased in women with prior anal sphincter injury? J Matern Fetal Neonatal Med 2006;19(11):723-7.

Martin S, Labrecque M, Marcoux S, et al. The association between perineal trauma and spontaneous perineal tears. J Fam Pract 2001;50(4):333-7.

Peleg D, Kennedy CM, Merrill D, et al. Risk of repetition of a severe perineal laceration. Obstet Gynecol 1999;93(6):1021-4.

My first birth, an 8-pound, 11-ounce baby girl resulted in a 4th degree tear (after an episotomy).  15-months later, I gave birth to an 8-pound, 12-ounce baby girl with no episotomy and a small tear that didn't even require a single stitch.  My OB didn't even suggest my not having a vaginal birth.

I did give birth in a side-lying position - which was great and slowed down a fast birth!

Have a wonderful birth!

Well, I decided to go for another vaginal delivery with minimal interventions after hearing of countless women who tore badly with the first doing just fine the second time around.  There isn't enough evidence out there to support a c/s after fourth degree tearing, IMO, but I will admit that it's nice to have that option, especaill if one has complications with the tear.  In any case, I hired a doula to help me through the process, about which I am really excited!  I'm due on 3/17/09, so wish me luck!  :-)

I know you will find the doula a boon. I certainly wish you luck. Please let us know how things go.

-- Henci

Oh my goodness!  What a relief to see that it is not such a high risk to have a vaginal delivery after a 4th degree tear!  My son is 15 months and it will be a while before we consider another one, but my ob is all but insisting that I have a section with any other children.  In fact, not 2 minutes after delivery the delivering doc told me that she would highly reccomend a section.  My labor was short for a first time, 6 hours start to finish.  I started out in the tub and I should have stayed there!  I ended up on my back.  I couldn't breathe and couldn't stay under control.  My son ended up presenting with his face up(posterior) and his head tilted to the side, as well as having an extremely tight nucchal cord...yes, I'm a nurse.  His HR dropped consistently to the 40's despite scalp stimulation.  The vaccuum was attempted approximately 5 times, all with pop offs.  Then the md just did what she had to do to get him out.  Adding to the complications, I hemmorhaged after ending up with an H&H of 5 and 17.  Despite all this I would rather do it all again than have a section.  Part of my dr's rationale for a section is that second babies are usually bigger.  My son was 7lbs5oz.  The position that he presented in with all the added complications was one in thousands.  Thank you for affirming that it is still possible for me to have a vaginal delivery!

You're welcome! I wouldn't be overly concerned about having a bigger baby next time. Your problems didn't have to do with the baby's size. Quite the contrary, the fact that you got a posterior, asynclitic baby out vaginally says you have room to spare.

Some women who have difficult births such as yours end up experiencing long-term emotional distress. If this is the case for you, I recommend Solace, a website for women who have had challenging childbirths. 

-- Henci  

I had a four degree tear at my second baby last June.  Baby too big she 8bl 14 onces.  Her shoulder stuck so the Dr. decide to take a scisor and do a quick snip so she can pull the baby out.  So I don't know if the push cause a big tear or because she snip me.  Anyway they give me stoll softener to use couple months.  I have no problem going to the bathroom, but I have a different problem after the healing.  Every cyle of my period I got sore around my rectum.  Or everytime I use the pad, tampon pad.  Its sour untill I'm done with the period and not using any pad.  I feel at the sour area its only at the rectum not at the virgina area.  And as I remember the normal rectom is closing tight before I got the snip and repair.  But after that repair the side next to my virgina which that where the tear running along the rectum its not deep tight,  it bumpy.  And its kinda swollen especially when its become sore when I use the pad for my periods. Its not level with the rest of my rectum circle.   ITS THAT MEAN THEY NOT DO A GOOD JOB AT SEWING ME UP?

Not necessarily, but something is certainly not right. Have your ob/gyn or midwife evaluate the problem. Maybe there is something that can be done about it.

-- Henci

I had 2 4th degree episiotomies (9# born 1987 and 11# born 1989). Now pregnant 20 years later I'm worried that the scar tissue will not stretch.  My doc is pro natural- baby should be smaller due to GERD diet... What is your experience with scar tissue stretching and/or the repair/healing of scar tissue if another episiotomy is needed? Terri

I can't speak to experience because I am not a clinician. I just read, evaluate, and put together the medical research. However, the second post in this thread--my response to the woman who started the thread--gives you the research data on how likely you are to experience another deep tear with this baby. The same post also has some suggestions for ways to minimize your chances of another deep tear.

-- Henci

I appreciate your informed and reassuring comments in the forum. I realize now that I had most of the risk factors for tearing in my first delivery, but due to being on blood thinners during the pregnancy, I'm not sure what I would be able to do differently the second time around. Do you have any ideas?

When a specialist discovered, early in the pregnancy, that I had a clotting disorder (protein C), I began taking heparin. The goal was to get me off of blood thinners right at 24 hours before labor and birth, so I scheduled an induction. Five days before the induction date, I developed Heparin-induced Thrombocytopenia and my platelet count dropped rapidly. I was induced the next morning. Knowing the pitocin would rush things, I wanted the epidural. She got stuck on the way out. He tried an episiotomy, and she arrived beautifully, but they had a lot of repair work to do on me. I apparently healed very well compared to many 4th degrees, but I'd rather not repeat the experience!

Next time, I could skip the epidural and birth on my side, but getting off of the blood thinners in time could be a real problem if I don't induce. Just thought I'd ask you and see what options might be out there.

If I understand your question (and please correct me if I am wrong), you are wanting information on optimal induction of labor so that you get off blood thinners before labor. Here are some recommendations:

• Hire a doula: If your goal is to avoid an epidural, she can help you do that. A doula can also provide encouragement and support through what is likely to be a rougher ride than with your own natural contractions.  
• Do not induce before the beginning of the 40th week, i.e. 39 completed weeks or a week before your due date: This minimizes the chances of the baby having serious respiratory problems.
• Do not use misoprostol (trade name: Cytotec, AKA "miso") if the cervix is not ripe: Go with one of the prostaglandin E2 formulations (trade names: Cervidil and Prepidil). These work equally well and while they are not risk free, they don't have quite the dark history of Cytotec. (See p. 8 of the FDA package insert.)
• Discuss oxytocin dose with your doctor if you think it won't be more trouble than it is worth--some obs may take offense: An oxytocin regimen that mimics levels released naturally and that takes into account how long it takes for any given dose to reach full effect will produce equally good results with less likelihood of problems. (See p. 6 of this oxytocin package insert.) 
• Do not rupture membranes until in active, progressive labor--if at all: If the induction doesn't take, you can stop it, go home, and try again another day.
• Arrange that once you are in active, progressive labor, they will try turning off the oxytocin drip: In many cases, once the pump is primed, so to speak, you will go on making progress with your natural contractions. If this doesn't happen, it can just be restarted. They (and you) will know within a fairly short time whether this is the case.
• Stay mobile and upright during labor: A good doula can help you find creative ways to do this hampered by the need for the IV pole and fetal monitoring.

That's about it off the top of my head.

-- Henci

If I understand your question (and please correct me if I am wrong), you are wanting information on optimal induction of labor so that you get off blood thinners before labor. Here are some recommendations:

• Hire a doula: If your goal is to avoid an epidural, she can help you do that. A doula can also provide encouragement and support through what is likely to be a rougher ride than with your own natural contractions.  
• Do not induce before the beginning of the 40th week, i.e. 39 completed weeks or a week before your due date: This minimizes the chances of the baby having serious respiratory problems.
• Do not use misoprostol (trade name: Cytotec, AKA "miso") if the cervix is not ripe: Go with one of the prostaglandin E2 formulations (trade names: Cervidil and Prepidil). These work equally well and while they are not risk free, they don't have quite the dark history of Cytotec. (See p. 8 of the FDA package insert.)
• Discuss oxytocin dose with your doctor if you think it won't be more trouble than it is worth--some obs may take offense: An oxytocin regimen that mimics levels released naturally and that takes into account how long it takes for any given dose to reach full effect will produce equally good results with less likelihood of problems. (See p. 6 of this oxytocin package insert.) 
• Do not rupture membranes until in active, progressive labor--if at all: If the induction doesn't take, you can stop it, go home, and try again another day.
• Arrange that once you are in active, progressive labor, they will try turning off the oxytocin drip: In many cases, once the pump is primed, so to speak, you will go on making progress with your natural contractions. If this doesn't happen, it can just be restarted. They (and you) will know within a fairly short time whether this is the case.
• Stay mobile and upright during labor: A good doula can help you find creative ways to do this hampered by the need for the IV pole and fetal monitoring.

That's about it off the top of my head.

-- Henci

If I understand your question (and please correct me if I am wrong), you are wanting information on optimal induction of labor so that you get off blood thinners before labor. Here are some recommendations:

• Hire a doula: If your goal is to avoid an epidural, she can help you do that. A doula can also provide encouragement and support through what is likely to be a rougher ride than with your own natural contractions.  
• Do not induce before the beginning of the 40th week, i.e. 39 completed weeks or a week before your due date: This minimizes the chances of the baby having serious respiratory problems.
• Do not use misoprostol (trade name: Cytotec, AKA "miso") if the cervix is not ripe: Go with one of the prostaglandin E2 formulations (trade names: Cervidil and Prepidil). These work equally well and while they are not risk free, they don't have quite the dark history of Cytotec. (See p. 8 of the FDA package insert.)
• Discuss oxytocin dose with your doctor if you think it won't be more trouble than it is worth--some obs may take offense: An oxytocin regimen that mimics levels released naturally and that takes into account how long it takes for any given dose to reach full effect will produce equally good results with less likelihood of problems. (See p. 6 of this oxytocin package insert.) 
• Do not rupture membranes until in active, progressive labor--if at all: If the induction doesn't take, you can stop it, go home, and try again another day.
• Arrange that once you are in active, progressive labor, they will try turning off the oxytocin drip: In many cases, once the pump is primed, so to speak, you will go on making progress with your natural contractions. If this doesn't happen, it can just be restarted. They (and you) will know within a fairly short time whether this is the case.
• Stay mobile and upright during labor: A good doula can help you find creative ways to do this hampered by the need for the IV pole and fetal monitoring.

That's about it off the top of my head.

-- Henci