I've interwoven my responses in red. -- Henci

Posted By Jenn Raven on 18 Jun 2010 04:26 PM

Hi Henci,
 
I've been reading through your website regarding women who have had successful subsequent births after 4th degree tears.  Unfortunately, I haven't been receiving the same type of support and data from specialists I've been seeing. 
 
My first child was born in June of 2008.  We weren't sure of his date of conception, so we let him go 10 days past 'due' before going to the hospital to be induced.  I was showing no signs of readiness for delivery- no real effacing, no dialation.  After receiving cervidil twice during my first 12 hours in the hospital, they started me on pitocin.  I labored down for another 5-6 hours and then pushed for 3 hours.  In the process of being induced, it was noted that my son was acyclitic.  I could feel him jabbing into the right side of my pelvis.  He was likely trying to turn, but didn't have a whole lot of space (or he was being rushed, which is my perception).  I finally delivered him OP after the midwife almost broke her finger trying to turn him.  With my final push and with vaccuum- assistance, my OB performed an episiotomy.  My doula claims that I delivered my son via 'vaginal c-section' since I was cut so deeply and not in a midline fashion.
 
I'm now 32 weeks pregnant with my daughter.  I have been to a specialist who says that I have about a 30-40% chance of permanent damange to my rectum that aren't directly visible from tearing during pregancy since that's just the outter muscle and tissue.  He explained that tiny fissures can occur on the internal scphinter muscle that aren't evidenced by outter tearing- and often they don't become problematic until later in life when muscle integrity starts to become comprised with age. 

The finding of invisible fissures in the rectal muscle is associated only weakly with anal sphincter incontinence, that is, many women who have them do not develop overt problems and some women who do not, do.  

After reviewing an ultrasound that was performed on my rectum in 2008, the specialist was incredibly surprised to see how well i've compensated when he performed an exam on my muscle strength at my appointment this week.  In 2008, I used to pass gass inadvertantly as well as have some incontenance.  Currently, most of this seemed to disappear with time and after performing regular kegels. 

Good for you! You have discovered what the research confirms: pelvic floor exercises can improve or relieve symptoms. 
 
I'm worried about the following concerns this specialist brought to my attention:

1.  That I might risking long-term permanent damange to my rectum resulting in permanent incontinence starting in my later years for the exchange of a short-term gain- a vaginal delivery for my daughter (which could still end up in a C Section or not). 

 Cesarean surgery does not confer any protection against anal incontinence. And having had a vaginal birth, you are unlikely to have a cesarean for a subsequent baby. 

2. That women who have permanent incontinence in their later years are 50-70% more likely to have depression.  I battled with serious post partum depression after the birth of my son and depression does run in my family.  I can't imagine spending the later years of my life with extreme intervention that comes with the disfunction of the rectal muscles.

I'm sure that is true, but if surgical delivery does not prevent incontinence, then it logically follows that it cannot prevent incontinence-related depression. I should add as well that few cases of what is termed "anal incontinence" are cases of fecal incontinence. Almost all are of gas incontinence only. 

3. I'm also worried about the exchange I am making regarding my body recovering from a C-section.  I want to know the effects it will have on nursing, etc.  I'm just not sure how to exchange the short-term for the long-term. I've heard that C sections don't cut through muscle anymore, but I'm going to have to do more research here.  Is there a way to have a 'natural' c-section or at least advocate the best c-section for me and my baby?

You are right to be worried about the difficulties of recovering from surgery while caring for a newborn, but that is not the only thing you should be worried about. CIMS has a fact sheet and model informed consent form form on the hazards of cesarean surgery. Notice that in addition to the immediate and short-term potential complications, cesarean surgery can also lead to debilitating chronic problems resulting from adhesions (internal scar tissue) and cesarean-related endometriosis.

I've been doing research, but i keep coming back to the same statement:  "Am I truly reducing the risk to me and my baby of permanent damange by having an elective c section, or am I just trading one risk for the other?"

"No" to the first part of your question, "yes" to the second part. Moreover, the risk of permanent damage during vaginal birth can be minimized by optimal care, but the risks of cesareans are intrinsic to having surgery.
 
I don't plan to have any further children after my daughter, which has been brought up as a factor that would push the specialist to tell me otherwise, since subsequent C-sections are more dangerous.

Planning not to have more children and not having more children are two different things. Substantial percentages of women have more than two children because they change their minds or have an unplanned pregnancy and decide to carry it through. Once you have a scarred uterus, you and your baby are at risk in future pregnancies and deliveries regardless of whether you plan elective repeat cesarean or vaginal birth. 
 
Any advice, direction, would be most helpful.

I hope I've helped. My last piece of advice is that your care providers appear to be pushing you in one direction: elective cesarean surgery, and, however well intentioned, they are doing so on grounds that are not supported by the research evidence. If you decide to go another route (pardon the pun), I would switch to care providers who are on the same road you are. The Birth Survey may help you find such a person in Phoenix. Once you have located someone, the Coalition for Improving Maternity Services has a pamphlet, "Having a Baby? Ten Questions to Ask"  that will help you confirm it. 
 
Jenn

Phoenix, AZ

 

Hi Henci,
 
I've been reading through your website regarding women who have had successful subsequent births after 4th degree tears.  Unfortunately, I haven't been receiving the same type of support and data from specialists I've been seeing. 
 
My first child was born in June of 2008.  We weren't sure of his date of conception, so we let him go 10 days past 'due' before going to the hospital to be induced.  I was showing no signs of readiness for delivery- no real effacing, no dialation.  After receiving cervidil twice during my first 12 hours in the hospital, they started me on pitocin.  I labored down for another 5-6 hours and then pushed for 3 hours.  In the process of being induced, it was noted that my son was acyclitic.  I could feel him jabbing into the right side of my pelvis.  He was likely trying to turn, but didn't have a whole lot of space (or he was being rushed, which is my perception).  I finally delivered him OP after the midwife almost broke her finger trying to turn him.  With my final push and with vaccuum- assistance, my OB performed an episiotomy.  My doula claims that I delivered my son via 'vaginal c-section' since I was cut so deeply and not in a midline fashion.
 
I'm now 32 weeks pregnant with my daughter.  I have been to a specialist who says that I have about a 30-40% chance of permanent damange to my rectum that aren't directly visible from tearing during pregancy since that's just the outter muscle and tissue.  He explained that tiny fissures can occur on the internal scphinter muscle that aren't evidenced by outter tearing- and often they don't become problematic until later in life when muscle integrity starts to become comprised with age.  After reviewing an ultrasound that was performed on my rectum in 2008, the specialist was incredibly surprised to see how well i've compensated when he performed an exam on my muscle strength at my appointment this week.  In 2008, I used to pass gass inadvertantly as well as have some incontenance.  Currently, most of this seemed to disappear with time and after performing regular kegels. 
 
I'm worried about the following concerns this specialist brought to my attention:

1.  That I might risking long-term permanent damange to my rectum resulting in permanent incontinence starting in my later years for the exchange of a short-term gain- a vaginal delivery for my daughter (which could still end up in a C Section or not). 

2. That women who have permanent incontinence in their later years are 50-70% more likely to have depression.  I battled with serious post partum depression after the birth of my son and depression does run in my family.  I can't imagine spending the later years of my life with extreme intervention that comes with the disfunction of the rectal muscles.

3. I'm also worried about the exchange I am making regarding my body recovering from a C-section.  I want to know the effects it will have on nursing, etc.  I'm just not sure how to exchange the short-term for the long-term. I've heard that C sections don't cut through muscle anymore, but I'm going to have to do more research here.  Is there a way to have a 'natural' c-section or at least advocate the best c-section for me and my baby?
 
I've been doing research, but i keep coming back to the same statement:  "Am I truly reducing the risk to me and my baby of permanent damange by having an elective c section, or am I just trading one risk for the other?"
 
I don't plan to have any further children after my daughter, which has been brought up as a factor that would push the specialist to tell me otherwise, since subsequent C-sections are more dangerous.
 
Any advice, direction, would be most helpful.
 
Jenn

Phoenix, AZ

Glad to have been of help! When you get pregnant again, make sure you discuss your history with your midwife. She may have some suggestions for how to minimize the chance of a repeat. One thing that comes to my mind is planning to give birth side-lying or on all fours so that you minimize pressure on the injured area.

-- Henci

Henci!

Your responses to all the questions you have been asked have been amazing. Thank you so much for you honesty and you sincerity.

I suffered a heamatoma after the birth of my third child however, it did not become painful until two weeks post-partum at which point I was rushed in for emergency surgery.

The heamatoma was so large that it had punctured a hole through to my rectum (fistula?) which was then stitched. I am assuming that the complications I experienced would be similar to those of a fourth degree tear, am I right?

I am now 18 months down the line and I have no further symptoms. At my check-up he was surprised at how well I had healed and said that the hole had completely closed and that the scar tissue was minimal considering what I had experienced (I didn't tell him it was all thanks to the arnica!!).

The surgeon then went on to tell me a c-section would be necessary if I were to choose to have any more children.

Having read through all of your posts, I feel confident that he was simply being dramatic and am happily considering child number four!

I would also like to add that I did have an episiotomy at my first labour and the site of the heamotoma was exactly where my scar tissue was...I am not sure if the two are directly linked but I suspect that the problem had been there all that time and was simply aggravated by a very quick labour (less than 20 minutes).

The pain I felt during the early contractions was huge and I am someone who usually labours on my hands and knees I found this impossible this time around as the pain was intense and nothing like my 'normal' labour pain. I knew something was not quite right but I felt fine for the next two weeks...until I stopped taking the arnica as it ran out and then it erupted!

I had my last two births at home and would love to do so again...so you never know!

I think it would be wise to be examined by an ob/gyn prior to conception though, just to ensure that all is well.

Thank you for restoring my confidence.

Best Regards

Natasha

Mary --

I'm pasting in Sharon Storton's response to your post below.

-- Henci

___________________________________________________

Dear Mary:

I am really glad that you found Henci's forum, and that you have been so active in your work to rein in this trauma.  Trauma often has 3 categories of symptoms: intrusions / avoiding / hypervigilence.  The intrusive symptoms include the flashbacks you describe.  Yours have been particularly severe.  Strong symptoms occurring every 20 minutes will level anyone!.  Nightmares come under this heading, as well.  The other 2 categories are avoiding whatever reminds you of the trauma, which may have been what initiated the idea for a complete change of personnel.  Good sense quickly joined that idea, and you are on to different care providers.  The last category is hypervigilence, which is often seen as "worry" or "anxiety."  It's that "cat-like" readiness for any other problems that may be nearby.  All that together can really send an already stressful situation - learning to care for a newborn as you heal from birth yourself - over the top!
 
EMDR has been found to be very useful for many "stuck" experiences:  trauma, grief (and that's such a big part of a difficult birth), anger that no longer serves you, etc.  I have personally experienced the use of EMDR for a trauma, and found it to be very useful when combined with a chance to process the situation.  I use it frequently in my practice as a therapist.  Candidly, it's like any other technique - it's not for everyone, all the time.  About 80% or so of women get good to excellent results, and about 20% say "it was okay, but..." or it did nothing.  For folks who either don't want EMDR or who are in the 20% for whom it's not great, I use hypnosis to "talk" to the symptoms.  What are the flashbacks trying to tell you that you have not yet seen?  If you pay attention, can you ask them to whisper an idea rather than shout a concern?  Combining that conversation with relaxation cues works well a good deal of the time.  Acupuncture is often extremely helpful toward abating trauma symptoms, and often helps with the sleep-related issues such as nightmares or insomnia.  I've seen some women who prefer medication, and use that for about 6 months in order to reset their systems from always being "on."  I've seen very good results when women work with a "Doctor of Naturopathic Medicine" (called a Naturopath, or a DN).  A naturopathic physician will often use amino acids, herbs, or homeopathic treatments to bring your system back down to a resting state.  The key is that you need to be able to enter a "parasympathetic" state once again.  It's the more calm, connective, gentle way of being in the world.  Mindfulness-based stress reduction techniques, a la Jon Kabat-Zinn, are often really useful toward claiming and maintaining a parasympathetic state.  There are many recordings and books on that topic.

Whew!  I hope this gives you many new options to consider without overwhelming you.  I think that reaching out, being so candid, and being proactive are excellent signs that you are tired of this situation making your choices *for* you.  While you may appreciate your body's resolute drive to keep you and your family safe, the threat is over now and you can welcome peace back into your birthing process.  

I am pleased to answer any further questions or thoughts that you may want to send my way via Henci.  I'm grateful that Solace was a safe place for you to find support.  

Take very good care,
Sharon Storton

Posted By on 20 Apr 2010 02:05 AM

Henci,

I experienced a fourth degree tear during the birth of my first daughter-- very long induced hospital birth with nurse-midwife and doula.   I had a surgical repair and healed well physically.  However, I developed chronic PTSD, which went untreated for a little over a year.  It was hell.  I eventually found support from communities like Solace and began seeing a psychologist every week.   After a year of therapy, I was feeling mostly back to normal and finally enjoying motherhood.   I was no longer bombarded every 20 minutes with intrusive thoughts and flashbacks. I learned to manage my PTSD triggers in daily life usually by avoiding or removing myself from stimulus.   I quit therapy about six months ago and continue to do pretty well.   

My daughter is now almost three and my husband and I are considering trying for a second child.  After reading through your posts, I'm gaining confidence that I could birth vaginally without a repeat of my last experience-- and thank you very much for that.  However, I still have a lot of PTSD triggers associated with birth.   Do you have any information on strategies women use to make vaginal birth after trauma physcologically tolerable?  We're concerned that I'm going to be plagued by panic attacks and flashbacks. 

I'm just exploring options at this point.  I will find a new doctor, new midwife, new hospital, new therapist, new doula, new childbirth instructor, etc. if we do decide to move foward.  I can't even consider moving forward without some sort of preliminary plan, so your research might be helpful in that regard.

Thanks,  Mary

-- Henci 

Posted By on 18 Apr 2010 03:55 AM

I did request a referral and my GP complied sending me to the nearest city. The specialist had thought that I healed remarkably well. I never had a fistula between anus and vagina - the repair muscled stayed intact. The sutured skin between the anus and vagina tore 10 days post op. I find it uncomfortable to wipe after using the toilet and tender during sex. However the specialist strongly urged me to refrain from seeking a repair of the skin as he stated the area was difficult to keep clean and infection could result. He also advised me, for the sake of this discussion, to once again have a natural birth. His suggestion was that should another tear ensue during delivery; another attempt then would be made at repair. He strongly advised that labour by planned c section was 100% chance of surgery where delivery naturally is not. Although he did mention his wife had fourth degree tear during first delivery and then went on to have another fourth degree and a third degree tear.

-- Henci

Henci,

I experienced a fourth degree tear during the birth of my first daughter-- very long induced hospital birth with nurse-midwife and doula.   I had a surgical repair and healed well physically.  However, I developed chronic PTSD, which went untreated for a little over a year.  It was hell.  I eventually found support from communities like Solace and began seeing a psychologist every week.   After a year of therapy, I was feeling mostly back to normal and finally enjoying motherhood.   I was no longer bombarded every 20 minutes with intrusive thoughts and flashbacks. I learned to manage my PTSD triggers in daily life usually by avoiding or removing myself from stimulus.   I quit therapy about six months ago and continue to do pretty well.   

My daughter is now almost three and my husband and I are considering trying for a second child.  After reading through your posts, I'm gaining confidence that I could birth vaginally without a repeat of my last experience-- and thank you very much for that.  However, I still have a lot of PTSD triggers associated with birth.   Do you have any information on strategies women use to make vaginal birth after trauma physcologically tolerable?  We're concerned that I'm going to be plagued by panic attacks and flashbacks. 

I'm just exploring options at this point.  I will find a new doctor, new midwife, new hospital, new therapist, new doula, new childbirth instructor, etc. if we do decide to move foward.  I can't even consider moving forward without some sort of preliminary plan, so your research might be helpful in that regard.

Thanks,  Mary

I did request a referral and my GP complied sending me to the nearest city. The specialist had thought that I healed remarkably well. I never had a fistula between anus and vagina - the repair muscled stayed intact. The sutured skin between the anus and vagina tore 10 days post op. I find it uncomfortable to wipe after using the toilet and tender during sex. However the specialist strongly urged me to refrain from seeking a repair of the skin as he stated the area was difficult to keep clean and infection could result. He also advised me, for the sake of this discussion, to once again have a natural birth. His suggestion was that should another tear ensue during delivery; another attempt then would be made at repair. He strongly advised that labour by planned c section was 100% chance of surgery where delivery naturally is not. Although he did mention his wife had fourth degree tear during first delivery and then went on to have another fourth degree and a third degree tear.

First of all, I wouldn't pay a lot of attention to the nurses' thoughts on the reason for your deep tear. It may simply have been luck of the draw or, in fact, you have less stretchy skin for whatever reason. It sounds like your problem went beyond an anal sphincter tear, though. It sounds like you developed a fistula, an opening between the vagina and the rectum, as a further complication. If this is the case, you may wish to consult with a specialist on how well it has healed (or consider repair surgery if it has not).

As for thinking about another baby, I am not a midwife or doctor, and you may want to seek advice from someone with a high intact perineum rate--the doulas in your community should be able to suggest some likely people or there may be a birth resource center or birth network group--but here are some suggestions of mine:

• Engage in perineal massage during pregnancy to gently stretch that area and to gain sensory feedback so you can feel how to relax those muscles consciously because they may tend to tighten in response to the pain of stretching during crowning. BTW, perineal massage during pushing has not been shown to prevent tears.
• Avoid an epidural because it limits choice of position and your ability to feel what you are doing when you push. This is already your plan.
• Push and give birth in a position other than the standard lying on your back with knees drawn back and wide apart, A.K.A. the "stranded beetle." This puts your perineum at full stretch already so it has nowhere to go. Giving birth lying on your side or on all fours keeps pressure off the perineum.
• A "hands off the perineum" policy as the baby emerges may be better than manipulating the baby or perineum, although with a birth attendant who has a high rate of intact perineums, I would trust her or his judgment.
• Pushing the head out in between contractions and refraining from pushing during contractions--think in terms of breathing the baby out rather than pushing--will help reduce tearing.

-- Henci

I had a fourth degree tear during the delivery of my first baby. The doctor and nurses described it as precipitous birth. I did not have an episiotomy, or assited delivery. I presented to the floor between 6 cm and 7 cm dialated - my delivery then stalled. The nurses encouraged me to push when I became suitably dilated, however I found it uncomfortable and did not feel ready. At their insistance I pushed several times, they then cautioned me not to push. The doctor arrived and pushing became involuntary, the head crowned. The doctor attempted to massge the area and ease the baby, but I could not control the pushing and the baby was delivered. The doctor initially thought I was a second degree tear and began to suture the area. Once he noted the tear to be worse I was sent to surgery for a full repair.

I was not informed of any problems with presentation - as an aside she was very low in the weeks leading to delivery and the doctors were unable to palpate her head. An u/s ruled out a breech birth but the technician commented on how low the baby was. When born baby had a severely coned head, in fact the nurses did not measure her length.

I am unsure if I will have another child or not. My thought is to once again try a natural birth. The fears associated with a bad tear were difficult to overcome and I have some ongoing symptoms; tenderness at the site (the sutures to the skin gave way leaving an open area between vagina and anus),during sex and bathroom cleaning. The first bowel movement was extremely uncomfortable and trying despite stool softeners - unfortunately pain management in the form of tylenol may have been at fault. After my delivery I was able to fully care for my daughter without limitations, as would be imposed with a c section.

I am an avid horseback rider and the nurses suggested that this may have strengthened my perineum causing it to tear rather than stretch. What are your thoughts on this?

I hope you get some responses from individuals, although the likelihood of a repeat tear depends on their care provider's practices during pushing and the birth. If you have not read it already, I have a post in this same thread dated 22 Mar 2007 that tells you how to minimize the chances of a repeat severe tear, and is, by the way, sound practice for any birth. I recommend that you discuss the recommendations with your OB. If your OB is open to them, you are on your way to an optimally managed birth. If not--and I find it concerning that your OB has recommended elective cesarean surgery seemingly without discussing its potential harms--then my advice is to find someone who is.

-- Henci 

 My first child was 8lb 8oz, I had 4th degree tear after an episiotomy. I am currently 5 months pregnant with my second child due Sept 6, 2010, My first child is turning 10 in July and I have had no problems. My OB suggested a c-section to prevent any repeat tear but will allow me to make the decision for vaginal or section birth. I am on the line as to what I want to do, I definately do not want longterm complications after another bad tear, but also the trauma of a section scares me too. I have read alot of the posts. I just wondered what the outcome has been for some of you that have went ahead with the vaginal birth after tearing. How did it go?

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

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.

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 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

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 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?

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  

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!

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

-- Henci

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!  :-)

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!

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.

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. 

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 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 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 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

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!