Permanent injury after birth vs c-section

One of my best friends who is 6 months pregnant with her second bub, likely to be her last, was told last week at her midwife appointment that she has a fairly high chance of her tearing just as badly, possibly worse as she did with her first baby. The midwife told her she could end up with permanent bowel incontinence, prolapse and/or other permanent injuries, and highly recommends she has a c-section.

With her first bub, she had a severe tear, which left her unable to walk for a little while after birth, as well as having the other issues involved with bad tearing (up into he vaginal wall and anus). She had a 4.5kg baby with a very big head.

My friend is very pro-natural birth. She is quite fearful of a c-section, but also just doesn't want to have one, and doesn't believe in having one, unless it's an emergency.

She is very torn in which way to go. Unsure of whether her care providers are scare-mongering or being right in their concern. She naturally doesn't want to have serious long term/permanent issues post birth, but she also feels like she doesn't want to be scared into doing something she doesn't want to or is unnecessary. She is trying to come to terms with the information right now.

Do you have an ongoing or permanent injury similar to what I have mentioned? Does anyone have any similar stories? Any advice or suggestions for my friend?

Not in the exact situation but I received third degree tears up to my bottom and also tearing of the vaginal wall when my DS was born one week ago. It was a VBAC. I am now in the situation of being absolutely terrified this will result in incontenance or a prolapse.

If I had had this birth first, I think I absolutely would have chosen a csection for a subsequent delivery. However it's all very fresh and painful for me so that could be clouding my judgement.

Without knowing her personal details it does sound a bit like scaremongering.
I have bad third degree tearing with my first, but with the following three absolutely nothing except so minor grazing at one birth. And I had a 10pounder born in the caul.
I would suggest she go and get a second (and third and fourth) opinion on her personal circumstance.

Her tearing sounds like it was quite severe. I am only speaking from my own experience. I Had a 4.5kg first baby with a 38.5cm head (and the little bugger had his hand up next to his face- just for added measure), resulting in 3rd degree tearing. My tears healed well, and no one ever suggested to me that I have a c/s for my next baby. I have quite a big frame though.
I was worried about my next births however as I had always heard that usually babies get bigger. For me though they got smaller (gestation got shorter, DS1 was 41+1, DS2 was 40 and DS3 37+5) and DS 2 was only 4kg resulting in an unsutred 1st degree tear, and DS3 was 3.5kg with only a graze.

Having said that, I think DS1 did plenty of damage, and I am now 8 years on, thinking I have a posterior vaginal prolapse.x

If she has the option, she should try to talk it through with a number of different midwives who can review her case and see what they suggest.

how troubling for your friend. I have a friend who had such severe internal tearing from her second bub, they put it down to how fast he came. but she ended up with a severe anal prolapse of 6cm the only way to fix it was a colostomy bag. that was 7years ago and she still has problems, so much so that the last 6months she has been going back and forth to Sydney to see top specilists.
in saying that there are ways to decrease tearing and the severity of tearing. water, hot peri pads, different positions. I guess its a matterbif looking into all her options. is she planning on having more kids? that might affect ger decision too

I just had a 4.8 kg baby eight weeks ago and suffered a fourth degree tear requiring stitching in surgery. fourth degree tears come with with a subsequent risk of faecal incontinence, prolapse etc etc.
I was told by one health professional that any future babies would need to be born by c section while another told me that is not necessarily the case.
I'm not planning on having more children but if I was your friend, I agree with above and would get multiple opinions from various health professionals ( OBs, pelvic floor physio and so on) and seriously investigate positioning during birth and would keep an eye on the size of bubs.
However, even having done all that I am sure there would be a risk of tearing again and it would be a personal choice to pursue a vaginal birth.
From a purely personal point of view, I wouldn't want to risk faecal incontinence and one fourth degree tear was enough for me and my poor pelvic floor.

It's so hard to know if there will be tearing, and if so- to what degree.... until it happens. Or doesn't.

I'm having a VBAC for this baby, and am paranoid about tearing, definitely!

The first thing that sprung to mind when I saw the title of the thread is that for me, IMO, c/s is a garaunteed permanent injury. The degree to which you're injured depends on a lot of variables. For me, I have little to no sensation around the scar. When I do have sensation, it's almost always pain and discomfort. Still. 2 years on. Let's not even get into the whole emotional side of my scarring.

It's a difficult choice. I would suggest maybe seeking a second opinion and going from there. And I think so long as her choice is based on fact, and she can be sure of this and comfortable with her decision - then everything will be just fine.

It's so hard to know if there will be tearing, and if so- to what degree.... until it happens. Or doesn't.

I'm having a VBAC for this baby, and am paranoid about tearing, definitely!

The first thing that sprung to mind when I saw the title of the thread is that for me, IMO, c/s is a garaunteed permanent injury. The degree to which you're injured depends on a lot of variables. For me, I have little to no sensation around the scar. When I do have sensation, it's almost always pain and discomfort. Still. 2 years on. Let's not even get into the whole emotional side of my scarring.

It's a difficult choice. I would suggest maybe seeking a second opinion and going from there. And I think so long as her choice is based on fact, and she can be sure of this and comfortable with her decision - then everything will be just fine.

I had a third to fourth degree tear for my first baby and it too quite a while to recover and i was not able to sit down properly or was terrified of pooping.

For sec bub the doc told me it was "recommended" that i had a c-section based on my history and also told me the reason with the tearing and that it could get worse etc.

Luckily i persisted as my 2nd birth i had a 2nd degree tear and recovered in two weeks.

Was very happy i stuck to my guns.

In having said that that was my experience so your friends doctors migjt have very valid reasons. All the best to her

I would be seeking some other opinions. even if they are not to disagree with her care providers but just to provide clarification and further information. that way she is making an INFORMED decision and will have given informed consent whichever way it goes ITMS. it makes a huge huge amount of difference to birth outcomes (both physically and emotionally) if decisions and consent are informed. ATM it sounds as though with the information that she has, that she doesnt feel informed and that has to change in order for her to find a good place emotionally to welcome this new baby.

I would definitely want to get further information from some one specialising in continence issues and/or childbirth before making a decision. I wouldn't have thought a general midwife would be the best person to give advice on her specific situation.

I had an episiotomy and then third degree tear with ds1, he was big with a big head and had his hand up by his face as well. With ds2 my ob was happy with vaginal birth but said i would need to have an episiotomy. Then he went on holidays and at 37 weeks i saw his partner, not-so-affectionately known as 'dr knife' who scared the bejesus out of me about fecal incontinence and strongly recommended a c-section, which I was very upset about. I sought other opinions and the consensus was that i could very well tear again and a c-section was not an unreasonable option. I booked the c-section as I knew that if i tore badly again I would always regret it. Luckily for me, I went into labour in the middle of the night and as I was being prepped for my 'emergency' c-section, my baby came so quickly that all the ob could do was to give me an episiotomy. DS2 was born in the room next to the operating theatre. I didn't tear at all, so was very, very happy that i escaped the c-section. Still very angry with dr knife about the whole thing. When my own ob came back from his holiday he said that there are two schools of thought about whether a c-section is needed after a third degree tear. He thinks no, his partner clearly thinks yes. I guess no one really knows if a woman will tear badly again, so it's a gamble. I hope your friend can get some useful advice and make a decision that she is happy with.

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how troubling for your friend. I have a friend who had such severe internal tearing from her second bub, they put it down to how fast he came. but she ended up with a severe anal prolapse of 6cm the only way to fix it was a colostomy bag. that was 7years ago and she still has problems, so much so that the last 6months she has been going back and forth to Sydney to see top specilists.
in saying that there are ways to decrease tearing and the severity of tearing. water, hot peri pads, different positions. I guess its a matterbif looking into all her options. is she planning on having more kids? that might affect ger decision too

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Wow, I really feel for you girls that have been through this - and your friends. I honestly think it must boil down to each individual woman. My last bub was 4.5kg and his delivery was lightning fast. Yet I only had a mild tear (second degree), and actually tore in the same place that I did having DS1 and DS2. I birthed while kneeling, and the tear gave me no problems whatsoever (though required a stitch). My boys don't have huge heads, but DS3 is/was pretty wide across the shoulders. So maybe the midwife isn't scaremongering? Maybe your friend might risk some serious health issues. If it was me, I'd be seeking a second, even a third, opinion to be more certain. Then I'd have a good weigh up of the facts. I think it pays to be mindful that the medical profession ere on the side of caution (er, big understatement) ... but sometimes it is with good reason.

Inducing early to avoid a large baby like the first time might be a compromise point? I would definitely get a second opinion though.

From a medical point of view, the current research does support having a ceasear after significant 3rd/4th degree tearing to prevent further bowel injury.
This is generally accepted practice now, although of course women are able to refuse and go vaginal, and defiantely it won't be a problem for some, you just don't know if you are going to be the one that is ok or not.
They aren't scare mongering- it is evidence based practice as far as I know ( might be wrong here) and a midwife is able to discuss this as it is probably policy at the hospital to suggest it.
Has she seen a physio after the last birth who specialises in pelvic floors? I would be discussing with someone like that too- they see women after birth and know all the ins and outs.

Personally I would probably go the LUSCS, but it is her choice and she can do her research into preventing tears etc, she will have a lot of scarring in the area which will have an impact.

She should also have a growth scan to estimate the weight- if it is assessed to be bigger that may sway her decision. Induction might be considered too.

I hope everything goes well either way x

It's a really hard choice to make. I had an episiotomy that tore further with my first and it was third degree.
Cs wasn't offered for my second but I was warned of the risk of tearing again. Thankfully I didn't tear at all second time around and only had a first degree tear third time.
It's a totally viable option for her to have a vaginal birth as long as she knows there is a possibility of it happening again.
It really is a personal choice. For me I would have chosen vaginal anyway if a cs was offered as cs is a major operation and I would have likes to take that chance of not having any stitches at all.

Thankyou so much everyone. My friend has read all of your replies and is going to see another midwife to check out what she has to say. She really appreciates all of your input, advice and suggestions.

I had a 4th degree tear with my first birth so I can understand your friend's concerns. I too am pro natural birth and had a great induction 17 days post EDD, pain killer free and it was just on delivery that things went pear shaped. I was very unwell for a long time afterwards and also developed PND because of my post natal gyno issues and not being able to physically care for my daughter unassisted for a long time. It was a huge shock that it turned out that way. When I fell pg with DS I started to do a lot of research into the risks and options for birth post 4 degree tear. There are a range of issues to think about and discuss with your caregiver. Your friend is 6 months so there is still quite a bit of time to make decisions. I certainly didn't make my decision until I was about 36 weeks and it was my decision not my Ob. As my pregnancy was incident free he was happy to go with what I decided and had of course put elective CS on the table.
The statistics are over 90% on the side of having no major tears the 2nd time around. However, the consequences for having another tear can be quite severe, especially rectal incontinence. I read lots of fabulous stories online of women who went ahead with a natural labour and all went well. I don't think I came across one woman that had experienced a 2nd major tear. However, that is not to say they don't happen. For me, I decided to put my long term health and happiness on the table as being important consideration. I looked at all the possible consequences of having a CS and weighed them up with my experience after having DD. I am 43 and decided to have an elective CS. It was a decision I have been extremely happy with. I had a great CS, strange and different experience than natural labour, but it was drama free, I breastfed my DS in recovery within 50 mins of his birth (I chose my hospital on the basis that they allowed this and provided a MW in recovery) and haven't looked back. My recovery was factors better than the 4th degree tear experience, absolutely no comparison IMO. My bonding with DS was probably better and faster too TBH, but hardly surprising as I had the most awful traumatic time after DD's birth. I am still coming to terms with all those experiences and feelings after the tear, and as my second pregnancy progressed they all came back, very strong and I found it difficult to make any decision without considering my own mental well being as well as the physical possibilities.
The CS bloody hurt in the 48 hours afterwards. But the pain quickly dissipated and as I had planned to be off my feet, I had a great support network up and running and was able to spend 4 days in hospital toddler free, sleeping, bonding and generally having a bit of a babymoon/holiday that I wouldn't have had. It also gave DH time and space to help me and DS and bond well too.
One other consideration I had was when to have the elective CS. Lots of OBs want to whip them out before the EDD but I was very keen to go as long as possible, and it was my OBs suggestion (he is awesome) that I have him up to a week after my EDD as DD was so late. I ended up having a 4kg healthy boy 9/10 apgars 2 days after my EDD and he continues to thrive.
I wish your friend lots of luck in deciding and with her birth!