Funny you should ask that right now. We have two mum's in care with
previous 4th degree tears.
( One of these happened a couple of years ago while under my care - as
prime with large baby but no other concerns, just happened. I had two in
one week and am hoping I will never see another. She also broke her
coccyx during that birth. What a loud crack it made!!!)
Anyway, both mum's in care now are having some fecal incontinence, which
has started during third trimester : ( . The one that happened under my
care was referred for physio after the birth which she went to for 6 weeks
but has not been religious about doing exercises since. Physio says she
has some muscle strength there. Mum is working hard at her diet to reduce
excess sugars/carbs to keep babe handleable size, which seems to be working.
We (midwives) have had some hemming and hawing about the possibility of
episiotomies with repairs at the time of birth, but seem to have decided
against this. The midwives would like to see them both attempt vaginal
birth without epis (haven't seen any evidence that epis would be
beneficial), see how they recover after birth and refer to an appropriate
surgeon (not obs/gyne) in a larger centre for assessment and subsequent
repair if necessary. Of course, if a 4th happens again they will need to be
repaired on site and then referred later. Discussions with mums about this
as potential plan is to occur yet. Both have requested consult to obs
(different docs) and we are waiting for responses - mums and midwives will
be unhappy if cesarean is suggested.
In the research I have done so far, it seems it is not just previously
torn muscles that contribute to incontinence. Pudendal nerve damage could
be the etiology. This would require different treatment than surgical
reconstruction, so assuming that one could "cut and then fix" at next birth
does not seem logical or humane. I am hoping both mums will have faith in
their bodies abilities to have healed well and that they will have less
trouble this time. Any other ideas out there?
Meaghan, in Canada
At 06:18 PM 8/29/05, you wrote:
Out of curiosity...... does anyone have any experiences of vaginal birth
following previous 4th degree tear? I've just recently met a woman who
wants to give vaginal birth a go - has new partner (says old one was
huge!). She is smallish person - 60kg, last babe 10lbs (1st baby). What
do you think. She will be birthing in hospital. I've asked her to get a
copy of her obstetric records from previous hospital. Still in early
pregnancy so can't gauge size yet. Is a later ultrasound a good idea for
a gestimate on the weight? I know they can be so inaccurate.
Kiwi Kim,
-------Original Message-------
From: <mailto:[email protected]>[email protected]
Date: 29/08/2005 11:10:23 a.m.
To: <mailto:[email protected]>[email protected]
Subject: [ozmidwifery] 3rd degree tears
Hi,
I've just returned from a clinical placement in SA where I spent a
mindblowing three hours in an incontinence clinic in an outpatients unit
at a major hospital.
The mindblowing element was the following statistics (copied from one of
the handouts):
* 39-49% women tear or have an episiotomy needing sutures
* 0.5 - 2.5% have a 3rd or 4th degree tear after vaginal childbirth
that is visible
* 25-35% after first vaginal delivery have a concealed or closed 3rd
degree tear, not visible
Listed as contributing factors were:
* 1st vaginal birth
* forceps/instrumental delivery
* long second stage >1 hour
* big baby >4kgs
* tissue type, short perineum, epidural, uncontrolled pushing, rapid
delivery, midline tear or episiotomy
The nurse practitioner stated this was all evidence-based information and
recommended c/sections to women who had had previous 3rd degree repairs -
these were the ones who knew about their tears obviously.
The handouts do not give references and as yet I have not had time to
begin researching.
Are you all as mindblown as I am??
What do you think - are 1/4 - 1/3 of us walking around with damaged anal
sphincters and not aware of it??
Where does this sort of information lead us - if our bodies are so inept
at giving birth then all first babies and subsequently all babies should
be born by c/section.
Sue
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