Do I have to have a "C" section after tearing with my first baby?

Dr (Osteopath)Fiona Hooper shares her personal experience with us all. 

TO CUT OR NOT TO CUT?
I can not believe it! 
I've qualified.

Winning!
 NOT!
Are they serious?  

I am now 36 weeks pregnant and I’ve met a different practitioner at every appointment and every one of them has heavily encouraged that I have an elective caesarean to avoid the chance of tearing again.

Yesterday’s appointment was the icing on the cake.

Going from recommending to now pressuring me into having a C section (CS) and because I continue to refuse a CS I’m now told I’ll need an episiotomy because having another tear is inevitable and out of my control.

Obviously my immediate reaction to the suggestion was definitely not.
However it was quickly followed by feelings of utter disappointment and sadness, that if I’ve been pressured into making this decision how many other people have been also (amongst other interventions). 
No wonder the statistics of CS births are on the rise.
 
Most of all I am bemused by the amount of people suggesting an elective CS as a way to prevent another tear. 
They are suggesting that I go for a guaranteed severe laceration of my abdomen, cutting through skin and muscle and increasing the risks of all sorts of complications (especially long term), instead of having a ‘chance’ of lacerations on my perineum second time around.
Swapping the possibility of one adverse outcome, for the certainty of another. 
 
What a dilemma to be in! 
 
So I’ve decided to delve into why exactly this was the case and what the statistics really were of a re tear, If it’s the real reason why they recommend this option in the first place and not just for practitioner preference, convenience or their lack of up to date education and knowledge.

So I’m taking my professional hat off and chosen to write this as a mum.

I’m also happy to share with you the statistics and 

recommendations I’ve discovered and what I intend to follow myself this time around if the circumstances permit.
 
For me, it’s all about weighing up the pro’s and con’s of my individual circumstance, however if I can avoid even one unnecessary CS today due to nothing other than convenience then I’ve done my job.

So, throw me the stats!!
 
Around 80-90% of women tear during childbirth.
 
Unfortunately, it is not always possible to predict or prevent these tears however there are certain risk factors you can look out for such as,

• A bubba more than 4kg in birthweight
• First vaginal delivery
• Instrumental delivery, particularly with forceps if bubba is ‘stuck’
• Position of the baby’s head
• Second stage labour duration more than one hour
• Induced labour
• Epidural anaesthesia
• Shoulder dystocia
• Midline episiotomy
 
It was challenging to get my hands on statistics, however the best evidence based stats are from England where there has been an increase in the rate of reported third and fourth degree perineal tears with the rate tripling from 1.8% in 2000 to 5.9% in 2011 among first time mothers.
 
Women with a previous tear who had a vaginal delivery for their second birth had an increase chance of severely tearing at 7.2%, compared to 1.3% in women who didn’t tear first time around.

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What are the current guidelines today?
 
The RCOG (Royal Collage of Obstetricians & Gynecology) Green Top Guidelines suggests that,
 
‘All women who have sustained a third or forth degree tear in a previous pregnancy and who are symptomatic or have abnormal endoanal ultrasonography and/or manometry should be counseled regarding the option of elective caesarean birth'.
 
'Women who have made an uncomplicated recovery and who have remained asymptomatic can consider vaginal birth again’.
 
Bang!  There’s my answer!

 
What’s the G.O with episiotomies?
 

Episiotomy during vaginal delivery was first recommended in 1920’s as a way to protect the pelvic floor from lacerations and to protect the baby’s head from trauma.
 
It was rapidly adopted as a standard practice and has been widely used since then. However, over the last several decades, there has been a growing body of evidence suggesting that an episiotomy does not provide short or long term benefits to the mother and may contribute to more severe perineal lacerations and future pelvic floor dysfunction.
 
Evidence based research has now suggested that the role of episiotomy in subsequent pregnancies is not known and therefore an episiotomy should only be performed if clinically indicated not ‘just in case’.
 
As an Osteopath I love this article extract! 
Highlighting the body’s ability to heal more effectively and efficiently from a natural trauma rather than a man made one.

'Many surgeons believe a surgical cut to be better than a natural tear, although scientific data has proven otherwise. The misconception stems from the fact that obstetricians are surgeons accustomed to sewing up openings that have been made with a scalpel. That is, cuts that are straight and clean. Whereas tears are ragged and irregular. It is perhaps counter intuitive to surgeons that a tear is better than a cut. What they don’t appreciate is that a tear follows the lines of the tissue, which can be brought back together like a jigsaw puzzle. An episiotomy cut, on the other hand, ignores any anatomical structures or borders and disrupts the integrity of muscles, blood vessels, nerves, and other tissues, resulting in more bleeding, more pain, more loss of muscle tone, and more deformity of the vagina with associated pain during sexual intercourse'. Marsden Wagner. Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First (p. 56). Kindle Edition.

'Many surgeons believe a surgical cut to be better than a natural tear, although scientific data has proven otherwise. The misconception stems from the fact that obstetricians are surgeons accustomed to sewing up openings that have been made with a scalpel. That is, cuts that are straight and clean. Whereas tears are ragged and irregular. It is perhaps counter intuitive to surgeons that a tear is better than a cut. What they don’t appreciate is that a tear follows the lines of the tissue, which can be brought back together like a jigsaw puzzle. An episiotomy cut, on the other hand, ignores any anatomical structures or borders and disrupts the integrity of muscles, blood vessels, nerves, and other tissues, resulting in more bleeding, more pain, more loss of muscle tone, and more deformity of the vagina with associated pain during sexual intercourse'.
Marsden Wagner. Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First (p. 56). Kindle Edition.

WHAT AM I GOING TO DO THIS TIME AROUND?

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These are the recommendations I’ve discovered so please take and leave what you wish.
 
Seek an Osteopathic treatment  - or the kind to evaluate your spinal and pelvic alignment.  A rotation in the pelvis for example may decrease the diameter of the pelvic outlet and thus decrease the room available for the baby's head.  Even 1 cm is going to be a game changer. Having an optimal pregnancy posture will also reduce tension on the pelvic floor muscles and pelvic ligaments (think of it as a hammock and having the ability to twist and torsion which will also hinder the baby's exit).
 
Don’t lie on your back during labour - Think of how your spine is curved and how your tailbone is tucked under.. When the baby’s head descends the coccyx moves out of the way. But it cannot when you’re lying on it.  Again decreasing the available space is going require your perineum to stretch more.
 
Kegal exercises -  only if you are inactive during pregnancy. I believe that you can also have a pelvic floor that is too tight if you over train these muscles. In my experience no patient ever does ‘too many’ rehabilitation exercises so I would perform these more for awareness especially if an epidural is performed.  This will give you some awareness of how to relax and contract this area when you cannot actually feel the body’s natural expulsion reflex to push/bear down and need to take your practitioners word for it.
 
Consider current nutritional status and general level of fitness and energy - Nutrition and fitness level is what provides the strength and elasticity to the connective tissues and muscles in the pelvic area.  Like the muscles in the rest of our body, if we are hydrated and fed nutritious foods we function at our best and exercise helps to keep the muscles toned and responsive to the task at hand.  My Naturopath has given me supplements to improve the elasticity of the previous scar tissue and tissue contractibility ‘down there’.  It may sound crazy but knowledge is power.

Perineal massage – yes you heard me. I will be honest, I skimmed over this with my first pregnancy. However after suffering a tear personally I’m very open to looking at all options to avoid a recurrence. Research suggests it’s only effective for your first delivery however I’m open to trying anything.  This can be done during pregnancy (from 36 wks) until the lead up or during the labour. It’s a pretty confronting type of option however worth considering.

Go for a swim - Well maybe a little soak in the bathtub during labour as this will soften the tissues and allow them to stretch with more ease.
 
Squat -  Squatting will allow gravity to act in your favour.
 

Warm compression to the perineum during the second stage of labour.
 
It’s important to make sure you avoid focusing on any fears of tearing. By worrying that you’re going to tear, you’ll likely end up tense and stressed, which can hinder the labour process and your experience of it. Your body is designed to birth – always remember that. Even if your ‘thinking’ brain says it doesn’t know how to do it, another part of your brain, the ancient brain stem, does. Your body effortlessly breathes, blinks, digests food, just as your perineum will stretch in order to give birth. You don’t need any fancy devices to make your body work better – after all, mother nature has worked beautifully all this time! You conceived, you can give birth too.
 
Quick labours also happen.  So if your labour is quick the rate of tearing may be higher also. You could consider trying positions related to slowing the birth by reducing the effects of gravity.  Knee-to-chest or lying on your left side with a pillow under the hips (this will still allow movement for the coccyx).
 
Focus on breathing, not pushing. I honestly feel the word ‘pushing’ needs to be removed from the birthing vocabulary.  This was my problem during my first labour.  I’ve watched all those Hollywood movies and being fit I thought, I’ve got this!  So I held my breath, didn’t listen to my body because I wanted it over with and pushed like I was running the last 100m of a race. Idiot!! Once the baby is low enough the automatic expulsion reflex takes over and it’s just the uterus doing the pushing. All I needed to do was breathe and bare down with it.  Hence why I’m doing hypnobirthing this time around.  Or you could try a           yoga or meditation for breath awareness.
 
 So what are my odds

 Ok, so I pretty much have a 5 fold increased risk of re tear, which is pretty obvious however I’m willing to take the risk by implementing the tips above.
 
Knowledge is power. Do your due diligence and question EVERYTHING! 
Otherwise I would be booked in for an elective caesarian.
 
We need to give our body credit where it’s due. We already know subconsciously how to give birth just like we don’t have to actively remember ourselves to make the baby’s heart, kidneys and brain for example.

IT JUST HAPPENS!

- Fiona Hooper Mpower Health