CS after VBAC

Hi girls
Almost a little scared to post as i am only 9 weeks pregnant, but i think i have to prepare myself. I had 3rd degree tear with my son (tore through my bowel) and was told when it happened that next time i would have to have a CS. Well its taken me a long time to get preg again and i knda thought that maybe i woould give a vb another go, but saw my ob yesterday who initally said i cant see why not, but on further discussion and examination said there is just not enough room and that the same will definately happen again. Exactly same thing happened my mum and she now has prolapse bowel, therefore CS is really the only option. So im just wondering when are CS generally done do you go to full term (40 weeks) or is it done earlier and is recovery as bad as everyone says ? would love some advise. thanks

Scooby,

Normally elective c/s are done approx 10 days earlier (not sure why?). I had an emergency c/s with DD and I recovered really well. I was walking around really well by the time I got home from hospital, and was doing everything normally, just no lifting or over exertion, and I was even given the ok to drive at 3 weeks post c/s. Everyone is different though and I know some women have a harder recovery. I think I was just v lucky. Even now, I dont have no trouble, never had an infection etc etc..

BOL

Lisa

Scooby,
I assume you mean VB (Vaginal Birth), not VBaC (Vaginal Birth after Cesarean)? It sounds like you've only had one bub so far and that was a vaginal birth... Sorry, I don't mean to be a know-it-all, jut trying to clarify...

C/S are usually done before your due date, at 38-39 weeks. This is so that you don't go into labour. They prefer being able to plan for the operation, I think, rather than having to do an "emergency" C/S.

If I was you, I would see whether I could get a second opinion about the neccesity of a C/S this time around. Your tear sounds pretty full on, your mother's even more so. But there are lots of reasons women tear, and some ways to manage/prevent it or reduce the severity.

Also, there is a case for going into labour before having a C/S. Some health professionals are of the opinion that it is better for both mother and baby if labour has started before the C/S was performed so that it is as close as possible to the physiological process of a natural birth. So this might be worth exploring, too.

Oh, and as Lisa said, some women find recovery from a C/S very easy, others don't. There is an increased chance of infection (along with other possible complications). You are also usally not advised to lift your baby in the first week or so after the birth. Some women find BFing more difficult, partly because the usual hormonal upheaval of a natural birth hasn't happened, partly because the scar might be painful and they find it more difficult to find a comfortable position for BFing. Having said that, some women find recovery from a vaginal birth difficult, too, especially if it was a difficult, long, drawn out labour.

Good on you for trying to get lots of info before making your decision!

Sasa

Thanks girls for the info
SS yes i mean VB not VB :redface: been in LTTTC too long!!!
OB was very keen on the idea of letting me have a vb as she said as long as i would have an episiotomy it should be fine as they will cut away from my back passage but when she examined me she said the perineum is just so short that its bound to happen again and really i see the embarrasement and pain my mum has gone through for years because of her prolapse, not fun and something i dont think i want to risk. I like that idea of going into labour first that makes total sense must check that out.
Lisa hope my recovery is as good as yours i think the most important thing to me is being able to feed and cuddle nothing else matters :lol: Again thanks soo much for taking the time to reply

I had a CS whith my DS and the recovery was OK. It took probably about 6-8 weeks to feel norma again. However, I had a VBAC with my DD and have had ongoing issues with an anal tear and nasty hemmoroids (sp?). It's been 7 months since she was born and I'm still suffering.

The reason they do electives a week or so early is because STATISTICALLY elective sections are less risky than emergency sections, but that is probably something to do with all the genuine emergencies in there - if bubs or mum is already in trouble when you operate the outcomes might be worsened by that, rather than the surgery. They also prefer to be able to schedule electives during the day for the hospital's convenience.

Talk to your ob about labouring for a bit first. In general it is MUCH better for baby to choose the birthday, as dates and scans can be out and many elective babies are premmie because of this. Even if you know the EXACT day you ovulated - sperm can live inside you for 5-7 days, so you've no way of knowing for sure what day it all happened. Some obs are very open to the idea of the baby picking the day and others are not, so asking is the only way to find out really.

As an aside, i know of a woman (friend of a friend) who had a 4th degree tear with #1 (7lbs9oz, 35cm head) (when she had an epidural and coached pushing and then ventouse) - she tore right through into her bowel for the last 4 inches of her vaginal wall and had 2 severe anal fissures too. She had #2 (9lbs1oz, 36.5cm head) at home without epidural or coached pushing, and though her pushing stage was longer (100mins) because she only pushed a tiny bit with each contraction, she didn't need a single stitch, got away with just a graze. In addition i now know 2 women who had c-sections who have now prolapsed. It can reduce the risk for some women, but please don't see it as a get out of jail free card - i would HATE for you to have the section to avoid prolapse and have one anyway.

In general women's perineal anatomy (barring actual abnormalities/birth defects) makes little difference to who will tear, as does scar tissue (which contrary to oft-told belief IS stretchy).

Things that make a difference are epidural or spinal anaesthesia (because you can't feel what you're doing), coached pushing (because you're not listening to what your body tells you), reclining pushing stage (because the weight of the baby is resting on the preineum as you push - on your hands and knees the baby's weight comes down evenly on the opening of your vagina, rather than more onto the perineum), fast pushing stage (because you don't have time to stretch), forceps or ventouse delivery (because the Ob is inclined to pull harder than you could push, which increases the stress on the whole area) and episiotomy. Your ob saying the episiotomy would be done rang alarm bells for me - episiotomies INCREASE the risk of tearing. Imagine trying to tear a towel in two, pulling on the edge. Now imagine you cut a nick in it with scissors first...! MUCH easier to tear. In addition, the kind of cut she was talking about is a particularly painful one - they cut sideways, towards the buttock, and if you tear at the epi site you can tear right into your glute, which makes sitting and walking painful for sometimes months. Emergency situations (vaginal birth of a baby with a prolapsed cord, birth of a breech whose head has become stuck and compressed the cord, forceps delivery of a baby who is in serious distress) warrant episiotomy, in general slow, gentle, delivery makes a FAR bigger difference.

If i were you (and i'm not so do feel free to ignore me!) i'd seek a second opinion before booking anything. You have time to research your options and strategies, which is a big bonus. :)

HTH in some way. :)

Bx

Hi Scooby,

I had an emergency c/section due to failure to progress, the bubba was just in the wrong place & too big for me. He arrived @ 9.30pm. I had a spinal epi. I was up the next day & he is fully BF. He was in the nursery the first night because he had to be in the humidi crib but otherwise he was with me. I was able to pick him up the next day & he has been full BF since birth, there was some pain when I BF a bit like a contraction but nothing too severe. The only painkillers I had beside the epi was 1 shot of pethadine at 4 am followed by ponstan & panadine forte/panadol regularly. I have had no problems with scar or infections etc... When I got home after day 5 (my milk took a little long to come in but I think that was because of the pethadine) I wasn't on any painkillers. I didn't overdo it of course as I had major surgery but that gave the time to be fully focused on DS.
If you have an option they do say that even some labour is good for the baby but from your experience I would want to have a c/section as being a real option.
My sister tore & her stiches got infected soI think there are risks no matter what we choose so try and be as well informed as possible & choose the right option for you.
GL &:stickyvibesgirl::pink-babydust: with your pregnancy.

Krisp: Big :hug: - I hope things improve for you soon

NJD: thank you so much for that info and im so glad that you were able to BF, it really is my biggest concern! I have been desperatly trying to get information on C/S but unfortunately all the literature is on how to avoid one, which is great, unless you are having one :doh: Ive had 3 obs and a midwife tell me its really not a good idea to have a vb including my family and friends who remember well the monthes of agony afterwards so i think cs is really the best option. WOuld really appreciate if anyone knew of some factual CS information for best recovery etc.
Once again thank you so much njd for sharing your story with me :hug:

Here are some facts for you

Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study (Villar, et al., British Medical Journal, 2007;335:1025, 17 November)
Study Design: Researchers assessed the risks and benefits of cesarean delivery vs. vaginal delivery.
Bottom line: Cesarean carries twice the risk of injury and death for both mother and baby. Women with cesarean experience double the rate of hysterectomy, blood transfusion, admission to intensive care, prolonged hospital stay and death, compared to mother who delivered vaginally. Babies born by cesarean were 45 percent more likely to be in the neonatal intensive care unit for 7 days and 41-82 percent more likely to die than babies born vaginally.

Risk of Uterine Rupture and Adverse Perinatal Outcome at Term After Cesarean Delivery (Spong, et al., Obstetrics and Gynecology 2007; 110: 801-7)
Study Design: Researchers examined the risk of uterine rupture after cesarean and what harms it may have for mothers and babies.
Bottom line: Regardless of how the baby was delivered, the rate of uterine rupture was low and complications from rupture were also low for both mother and baby.


Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births. (Declercq, et al. American Journal of Obstetrics and Gynecology. 2007 Mar; 109(3):669-77.)
Study Design: Researcher divided mothers into two groups: women with a planned cesarean after no labor and women who labored and had either a cesarean or vaginal birth and then compared rehospitalization rates.
Bottom Line: Rehospitalizations in the first 30 days after giving birth were 2.3 times more likely in planned cesarean than with planned vaginal births. The leading causes of rehospitalization after a planned cesarean were wound complications and infection. Hospital costs were 76 percent higher for women with planned cesarean, and hospital stays were 77 percent longer.


Previous caesarean or vaginal delivery: Which mode is a greater risk of perinatal death at the second delivery?
(Richter, et al., European Journal of Obstetrics & Gynecology and Reproductive Biology 2007; 132: 51-7)
Study Design: Researchers compared mothers who had delivered previously by cesarean vs. vaginally, and examined the number of babies who died in the subsequent pregnancy.
Bottom line: A previous cesarean delivery was associated with a 40 percent increase in perinatal death (the first week after birth) and a 52 percent increase risk of stillbirth. A vaginal or cesarean delivery in the current pregnancy did not impact the death rate.


Postcesarean delivery adhesions associated with delayed delivery of infant (Morales, et al., American Journal of Obstetrics and Gynecology 2007; 196: 461.e1-e6
Study Design: A common complication of any surgery is overgrowth of scar tissue, called “adhesions.” Researchers examined the frequency of adhesions with successive cesareans and whether adhesions caused by cesareans could slow down the delivery of a baby in the next pregnancy.
Bottom line: Researchers concluded that each successive cesarean significantly increases the incidence of adhesions and can slow down the delivery of a baby. One prior cesarean adds 5.6 minutes to the time it takes to deliver the baby, 2 prior cesareans 8.5 minutes, and 3 prior cesareans 18.1 minutes. This delay can compromise the health of the baby, researchers concluded.


Association of caesarean delivery for first birth with placenta praevia and placental abruption in second pregnancy. (Yang, et al., British Journal of Obstetrics and Gynecology: 2007 May;114(5):609-13.)
Study Design: Researchers examined the incidence of placenta previa (placenta blocking the cervical opening) and placental abruption (placenta separating from the wall of the uterus prematurely) in women who have had a prior cesarean vs. a prior vaginal delivery.
Bottom line: Compared to vaginal birth, cesarean increased the risk of placenta previa by 47 percent and placental abruption by 40 percent. Both complications carry the risk of death for both mother and baby. Researchers indicated that complications may be due to the cesarean scar on the uterus.


Risks of adverse outcomes in the next birth after a first cesarean delivery. (Kennare, et al. American Journal of Obstetrics and Gynecology. 2007 Feb; 109(2 Pt 1):270-6.)
Study Design: Researchers examined the complication rate of women who delivered their first baby by cesarean vs. vaginally.
Bottom line: Women who had a prior cesarean delivery were more likely to have complications than women who had a prior vaginal delivery. Women with a prior cesarean were more likely to have a placenta previa (odds ratio [OR] = 1.66), placenta acreta (OR = 18.79), and bleeding during pregnancy (OR = 1.23). During delivery, women with a prior cesarean were also more likely to have a prolonged labor (OR = 5.89), uterine rupture (OR = 84.42), and need an emergency cesarean (OR = 9.37). Babies born to women with a prior cesarean were more likely to be small for their gestational age (OR = 1.12), have a low birth weight (OR = 1.30), and to be still born (OR = 1.56).


Safety and efficacy of vaginal birth after cesarean attempts at or beyond 40 weeks of gestation. (Coassolo, et al., Obstet Gynecol. 2006 Jan;107(1):205)
Study Design: Women who attempted VBAC before the estimated due date (EDD) were compared with those at or beyond 40 weeks of gestation. Researchers assessed the relationship between delivery after the EDD and VBAC failure or complication rate.
Bottom Line: The risk of uterine rupture (1.1 percent compared with 1.0 percent) or overall morbidity (2.7 percent compared with 2.1 percent) was not significantly increased in the women attempting VBAC beyond the EDD. Women beyond 40 weeks of gestation can safely attempt VBAC, although the risk of VBAC failure is increased.


Incisional endometriomas after Cesarean section: a case series. (Minaglia, et al., J Reprod Med. 2007 Jul;52(7):630-4.)
Study Design: Patients were identified who were diagnosed with incisional endometriomas (functional endometrial tissue outside the uterine cavity, within the incision) after undergoing cesarean section.
Bottom Line: The overall incidence of incisional endometriomas following cesarean section was 0.08 percent. Optimal treatment is by surgical excision.


Predicting Failure of a Vaginal Birth Attempt After Cesarean Delivery. (Srinivas, et al., Journal of Obstetrics and Gynecology. 2007 Apr;109(4):800-5)
Study Design: Researchers analyzed the records of women offered VBAC in 17 community and university hospitals, to identify any factors that could be used to predict failure in attempting VBAC.
Bottom Line: Prelabor and labor factors cannot reliably predict VBAC failure.


Caesarean delivery and risk of stillbirth in subsequent pregnancy: a retrospective cohort study in an English population. (Gray, et al., BJOG:2007 March 114(3) 264-270)
Study Design: Researchers compared the incidence of stillbirth following a previous cesarean section with stillbirths following no previous cesarean section.
Bottom Line: Pregnancies in women following a pregnancy delivered by cesarean section are at an increased risk of stillbirth.


Predicting placental abruption and previa in women with a previous cesarean delivery. (Odibo, et al., Am J Perinatol. 2007 May;24(5):299-305.)
Study Design: In women with a previous cesarean section, researchers compared those who had a placental abruption and/or previa with those who did not.
Bottom Line: Three or more previous cesarean sections was a significant risk factor for placental abruption and previa.

Hi Alan
Thanks for that, it is very similar to info i have already assessed, i actually titled this wrong as i havent had a previous cs my son was born by VB but i had 3rd degree tear, he popped his lung and i went on to almost a year of infection and rehabilitaion and things are still not 100% almost 5 years later. I have been told this is an anatomical problem ( very short perineum) like i said by 3 obs and 1 midwife. I have had to have 18 monthes of fertility treatment to fall pregnant again and also had an ectopic at the end of last year. This will be my last pregnancy as 2 children is all i ever wanted. All this said i have pondered over VB and CS for the whole time i have been trying to concieve and i study natural medicine so medical intervention is just not something that i wanted, but the 5 % chance of ending up with a coloscopy bag is really swaying my decision. All that said i know CS has a bad rep i know all the risks and i feel i have done my home work on this, i really want info that can help me get in the best possible shape before the cs and how to get better as quickly afterwards and as i have said to be able to BF my baby is the biggest issue !!! i even down loaded a copy of the The cesarean booklet and its full of the info you gave me. i really do feel i need support in my "choice" and unfortunately there is none out there except from the women who have been through it.

Hi Scooby,
I can understand why you would be inclined to have a c/s given your circumstances. When I go for round 2 I would like to try for VBAC but as I have already had a c-section the chances are I may need another c/section therefore there are things I would do before the birth to prepare for that option. The thing I remember the doctor saying is that I was healthy & that would go a long way to helping with the recovery.
I would express the colostrum so that there is some for when I am in recovery (they give it to the bubs via a syringe generally to avoid the nipple confusion that can occur with a bub). This would also have to help with bringing in the milk. I would do some searches on BB there seems to be some natural things like alkivite & Fenugreek & flaxseed oil that you can have on hand if you need do to boost your milk supply. Be fit, now this doesn't mean doing marathons but do some gentle exercises & be active, I tried to walk most days - this includes incidental walking eg to the shops, around the shops etc... I did tummy excercises where you pull your belly into you to help the muscels. I mostly got my inspiration from the pregnancy books I got in the hospital showbag you get when you book into the hospital & from the antenatal classes. I wasn't obsessive or anything but tried to do some every few days for about 10 - 20 mins, it wasn't always all at once either I would do 1 set of exercises & then some later.
Be prepared - which is what you are trying to do, read up on some pain managment. Check your hospital policy to see if DH can stay with you overnight if that is an option if you have someone to watch your DS especially for the first night or 2. My DP didn't stay overnight but he was there for as long as possible & a great help.
Remember - take your pain medication when it should be taken to keep on top of the pain, as my dr explained that way you can recover quickly. Try to get up as quick as possible after the op. Always breath. If you are having difficulties picking up bub the midwives are there to help you, don't be afraid to buzz them to come & get your bub for you that is their job afterall.

Anyway GL with whatever you decide & I hope this helps. If you have any questions don't hesitate to ask. :hug:

NJD: Thanks so much that is all the type of info i am after and it all makes total sense. Im actually abit of a gym junky and stopped for a little while because i got hyperstimulation from the ivf meds i started back for about 4 weeks but my 12 week scan showed my placenta was lying very low and i have had some spotting, so my ob has banned the gym in the meantime but hopefully they will let me back soon, BUT i will keep walking. Sorry to keep buggin you but what pregnancy books did you have i just cant seem to get any info, i think i must be looking in the wrong place!? Once again thank you.

Scooby, first of all sorry you had such a difficult birth with #1.
Just wanted to say my stepmother had 3 c/sections for reasons I won't go into, always recovered amazingly well - I was surprised to find out that recovery is 6 weeks as she always bounced straight back and after a week in the hospital was at home looking after her kids and showed no ill effects at all. All three were fully breastfed from Day 1. So I think it just depends on the person, and you can have a swift and full recovery and establish BFing after a c/section. If you have decided this is right for you (and to be honest, in your shoes I would do the same) then go ahead and be confident that you will recover quickly.
:hug:

I have not read the other replies but....

My hospy want to take my baby at 38 weeks, but this is because of risk of uterine rupture (pffft)
So they want me to avoid labour completely.
Do you need to avoid labour?

Pixie: thanks for that, yes i think a psitive outlook and getting back into things (slowly of course) may be the best way, i aprreciate your support thanks. Good luck too not long to go :dance:
MTT: yes its on my list of things to ask my ob at next appointment, it definately sounds good if you can go that way it makes total sense, thanks and good luck to you.
My ob has actually said that if the baby comes early 37 weeks i may be able to try a VB not sure how i feel about that as im not sure how great it is for bubs to come that early, DS was 2 weeks over ! but would love to go a VB.

Scooby, I have just realised you are in Perth & the books I am referring to are done by the NSW hospitals. I would be happy to photocopy the pages about exercises & post them to you if you would like??

Scooby - I am sorry that you suffered so much pain with your first birth. I had an elective c-section for DS, and my doctor took him out at 39 +1 weeks. But most hospitals/OB's have their own sort of preferred time line, as well as what actually happens ie, recovery.
My section was fine, I healed great (can't really even see my scar 18 months later) and I was up and walking the next morning (albeit very slowly!!!).
Unfortunately BFing didn't work for us, but I doubt that had anything to do with the c-section, more just bad advice from midwives, and poor attachment, and the fact that DS had neck issues which did not help him attach at all without pain.

My sister has also had 4 c-sections, and she said that she heals better each time, and she has BF 3 of her children successfully (one of her c-sections was a stillborn).

If I can help with any other information from either my experience, or my sister's, please feel free to ask away!!

I'm curious though, as I am going for my VBAC - when you say that your perineum is short - how short is "short"? Cos I have always thought that mine was quite close to my girlie bits and would be interested (if you are willing to share) as to what they consider short to be. (I've never thought to ask my OB, I'm a little shy.. )

What you "see" as the perineum is only about 1/3rd of it, the rest of what becomes perineum during birth is inside the vagina most of the time - that's why perineal massage is done with the thumbs inside the vagina. At the end of pregnancy the whole area "relaxes" so the distance front to back gets much longer. And if, like me, you tore and were not stitched the perineum can look a lot shorter afterwards.

I just measured (hilarious and strangely scientific) and mine (from bottom of vagina to edge of anus) is 1.5cm stood up and 2cm if i lie down. I'm not pregnant though.

Bx

Hoobs - I'll have to get DH to measure mine.. obviously I can't even reach that area at the moment... LOL

lol - everyone reading this will be sneaking off to measures theirs now too Hoobley!:lol:

I had an elective c.s with DS. And although recovery time for me was a bit slower than others I healed well and didnt suffer much pain or any complications.
Ds was delivered at 39wks.
He was put on breast and sucking within half hr or birth.
I have many friends who had natural vaginal births who were not able to get baby feeding well or as soon - so I think that unless theres some other complication with the delivery, then c.s or V.b, makes little difference to how bf will go.
Being in fit and healthy state before hand and being aware of the procedure (as it sounds you are) is bound to make a difference to recovery.
I was fit when I had ds and recovery mentally and physically was good, but I had abdomo surgery last year during a stage when I had gotten quite unfit and recovery emotionally and physically was difficult.

Heeee :lol: this thread has taken a different sort of turn and hoobley thank you so much for doing that,:hug: ive often wondered and actually thought of looking up porn sites just so i can see:rolleyes: (very embarrsed) any way as part of science and all i have tried to measure, but it does seem there is no real "flat" bit to measure any way it would be under 10mm but it kinda feels like there is a piece of skin about as thick as my earlope and shaped the same dividing the 2 parts, hope that makes sense?!?!?! i know when ive looked in my anatomy books it seems to be a bit longer and have more of a "flat" bit than what i have.
To all the replies thank you soo much for your support and advise you dont know how much i appreciate it thank you.
Njd: thank you so much i would love that info can you PM me your address and i will send a return envelope and money order for the photocopies, or if youd prefer i can deposit it into your bank account what ever is easiest. i really would love that info.

Scooby - yes I've looked at the porn girls before too.. pmsl... I don't think it helps that I compare it to a guys and apparently guys poo holes are much further up (well appear to be because of the ball sack..PMSL)
ahh what a conversation. This is what me and DH were discussing in the bathroom before anyway, but he has agreed to measure mine for me later on.. .LOL

I'm very curious from your description though....

The gap in men is much bigger, so no go for comparison.

It sounds like your tear has healed so that the scar tissue sits "tighter" which seems to create the divider?

If i measure from the end of the tear (which was only first degree but "gaped" because of it nicking into the muscle a little, so there is a visible nick in the skin rather than as you say, a flat bit) it's about 1cm, maybe a little less. But i can't get my finger "in" it, if i try it slides back towards my vagina proper, if that makes sense. It's like the tear left a sort of more sloping vaginal entrance on my perineum in the flesh. Does this make sense?

Bx

ETA, actually i realised you might mean the "lobe" bit of skin is sitting across between vagina and bum - mine doesn't sit that way unless i'm standing up and i think of it as just skin, whereas my perineum is the muscle underneath. See that in part is why i don't get how it can be "too short" because it's the muscle that maintains vaginal/rectal integrity and during pregnancy you're SUPPOSED to be able to compress the muscle to paper-thinness - it makes the maximum amount of room in the pelvis for bubs to fit out... I'd love to quiz the Ob on what they actually MEANT. LOL

Hoobley, you are an encyclopedia - better even. Amazing the detail you seem to know about pretty much everything!
I'm no expert, but I wuld think that the ob is concerened that if the perineum is "short" that any tear, even a tiny one, would be severe... just my interpretation.
To be honest, it sounds very strange to me. But obviously a few OBs and midwives have come to the same conclusion independently.

Saša

I had a CS for a breech bub, and have previously had a couple of rounds of major pelvic surgery. Here's some of my tips to make it easier - I'll keep adding to them as I remember:
1) When they say "nothing to eat or drink after midnight" it is worth having a drink and snack at 11.30. Anxiety about surgery is bad enough without adding major hungry and thirsty.
2) After the surgery drink a little water very often. Start eating gently though - throwing up with a cut tummy aint fun.
2a) If you feel at all nauseous tell someone - there are meds to stop you chucking and they are worth using
2b) Take pain meds as suggested initially, and don't wait for the pain to get really bad before taking the next dose - take the next dose as the pain starts to worsen. It's important for you to be mobile as soon as you can after surgery (even if it's just wriggling in bed), and the pain meds will help you do this.
3) practise rolling from back to side without using your tummy muscles beforehand. I find that if I tense my bottom and pelvic floor I can then pull myself over with my arms and not stress my tummy at all - find what works for you
3a) similar idea for getting up
4) Granny undies - several sizes bigger than pre-pregnancy. So nothing rubs or squashes your cut
4a) big, soft clothes (yoga pants, pj's, trackies, whatever - but nothing with a zip or other stiff material). You don't suddenly shrink after a c-section, so whatever fit late in pregnancy will probably be fine here too.
4b) avoid long nighties - getting them out from under yourself so that you can bfeed is really awkward.
5) bfeeding lying down was great for me - but do keep bub's legs wrapped up or put a thick towel over your tummy, 'cause a kick in the tummy (even from a little baby) hurts lots
6) put a folded up jumper or baby blanket or similar between your tummy and the seatbelt on the way home
7) pack your stuff for hospital in several little bags. It means that when you pack to go home you can lift the damn things!

hth a bit
Kate

To be honest the obs have always drawn a diagram im not sure if theyve named it as such, but the skin between the anus and vag is the perineum, the perineal muscle is what is underneath, actually found this hope im allowed to transfer this info:
First degree tear - tear involving the perineal or vaginal skin only
Second degree tear - perineal skin and muscles torn, but intact anal sphincter
Third degree perineal tear - perineal skin, muscles and anal sphincter are torn
a. Less than 50% of the external anal sphincter thickness is torn
b. More than 50% of the external anal sphincter thickness is torn, but internal anal sphincter intact
c. Both external and internal anal sphincters are torn, but anal mucosa intact
Fourth degree perineal tear - perineal skin, muscles, anal sphincter and anal mucosa are torn
Button-hole tear - anal sphincter is intact but anal mucosa is torn
i think really they are saying that because the area of skin is so short, next to go would be the muscle and the existing scar tissue would lead straight to the anus, but i will ask the ob ill add it to my never ending list :lol: i think i may need 2 appointments back to back
Yes i do mean that if i put my thumb at my vag opening and fore finger at my rectum it feels the same kinda width as if i do the same to the bottom of my ear lobe. (what a lovely conversation)
Kate: that was amazing info thank you so much and i would really appreciate anything you have to add thank you

Hi Scooby,

Congratulations on your pregnancy! Good on you for thinking about this so early, the more time you have to research and think the more ready you will be to make your decision.

I haven't have a c/s so sorry can't give any advice from a personal position, however, I have supported women through c/s as a doula and I have seen that they really can be wonderful and joyful experiences, just as vaginal births can be. I would recommend that you consider maternal assisted c/s and also just have a really good think and write a birth plan for the c/s if you choose to go down that path! Just because you choose to have a c/s certianly doesn't mean you have to hand over all control over about the kind of birth you would like to have.

I hope you have a happy and healthy pregnancy and good luck making your decision. You are the only one who will know what is best and don't let anyone make you second guess your decision or make you feel bad about it!

Did some pubmed searches, found some studies:

The perineal body length and injury at delivery.

Risk factors for perineal injury during delivery.

Is primiparity, the only risk factor for type 3 and 4 perineal injury, during delivery?

Basically i found that i have an extremely short perineum. Long is over 6cm, average is 3-6cm, short is less than 3cm. The studies which looked at risk factors concluded forceps, posterior presentation and being a first time mum posed the most risk. In the perineal length study, perineal length was found to have no bearing on damage whatsoever.

Bx

Hoobley they are really interesting studies, and worth a read i have done abit of a scholar search before and i just wish there was studies done on 2nd and 3rd pregnancys, this has been my point all along there just isnt the information and or studies, iget the point of everything thats in those studies i had an episotomy with DS, he was also not lying straight and he was birthed by vacumn extraction, i realise some or all of these could have caused my tear, but i still have no where to go, where are the studies on the chances of it happening again, why even with my history would an ob say yes to a natural birth then examine me and say they wouldnt reccommend a VB, i really want some answers and i guess i need to talk to my ob about the info i have come across and find out her reasoning. i really apprecite your help through this process and man am i glad i started so soon :lol: welll im going to go watch some mind numing telly so i can hopefully get some sleep tonight
Jas: thank you i know no matter what it is up to me what kind of experience i have and definately will have a birth plan in place and the wonderful thing is the ob i have is very well respected amongst other women who have had her as there ob, she is kind, gentle and very willing to listen i feel total blessed to have found her, the great thing is the midwife she works with actually helped me through my fertility treatment as well so i feel really comfortable with them both thankfully. i wanted to say that i highly respect the work you do and what you have said means alot to me, so thank you.

Scooby, I know your planning on having a c section. But I thought that I would post this to you anyway.

Just over a month ago I supported my first client as a doula. This was her 3rd baby. Her first birth ended in a massive tear (4th degree) into her anus, she pushed for 3 hours and had a failed vacuum, forceps delivery. She has suffered with mild bowel incontinence on occassion.

Second bub was another vaginal birth and she had an episiotomy after pushing for a couple of hours.

With her last baby she was getting scared. The hosp had told her bubs head was BIG. This frightened her to no end. They had suggested she could have a c section. She wanted desperatley to have a vaginal birth but at the same time was scared of the damage that had been done to her previously.

My client was using EPO as it helps to soften scar tissue. As you would know scar tissue doesn't stretch like normal tissue. My client had an episiotomy once again, but pushed bub out on her own steam in under an hour. She has had no bowel issues since bubs birth. Bub was born the day before his due date. Mum was not prepared to go over dates though as she was worried about the extra growth. FWIW, bub's head circ was only 35cm. So not huge at all.

Goodluck in whatever you decide. Your body, your birth and your baby huni. :hug:

Hi scooby,

You're so right, it's frustrating that there aren't purer multipara studies. I'm searching searching searching but all i can find out is that for multipara's perineal injury is twice as likely with episiotomy or instrumental assisted delivery...which we already knew! I think there are too many factors to do a clear study. Like they need multiparas who had a 3rd or 4th degree tear last time and who then went on to have a natural (or at least vaginal, epidural and pethidine-free, non-episiotomy, spontaneous delivery without positional restrictions and coached pushing) delivery and that's REALLY hard to do in a hospital, so the studies instead focus on the risks of those things (instruments, epi's, drugs, positions etc.). The fact that studies find primiparas at higher risk means there is an inherently lower risk for multipara's, but that is statistically over all women, not isolating only those women who already suffered significant perineal damage.

From the reading i've done today i would say if you had a spontaneous vaginal birth without epidural and gave birth on hands and knees or in a supported squat, and did not push once the baby was on the perineum, and maybe even had a waterbirth for perineal support, i'm sure you could get through without a serious tear (to the point that i would advise a close friend to go for it if they were considering it, rather than just telling a stranger on the internet to do so!). BUT i don't know how easy it would be for you to GET that kind of delivery, and the risk of tearing remains if anything on that list is missing or ignored by your caregivers. And birth is so personal - i could see me easily achieving that sort of birth because of my previous experiences (which were not at ALL like yours, i was at home, the midwives came only an hour before i delivered and i did whatever i wanted, when i wanted, where i wanted (almost had her in the loo!)), but i have many friends who simply couldn't consider such an approach without being terribly afraid and i really don't blame them given their own experiences.

I'll keep looking and see if i can find anything more for you. I think for you a vaginal birth would be possible, but there might be a long road ahead to get to a place where you want to attempt it (and by that i mean getting to a place where you are TRULY happy and ready to do it and not doing it because of feelings of fear, guilt or any other negative feeling women have put on them around birth) and where you have a supportive caregiver. I guess it depends on what it means to you. I think a successful vaginal birth could be very healing for you, and it is certainly very important to some women (not sure where you would stand on that one) BUT i think it might involve a lot of "fighting" to get it the way it needs to be for you, and if a peaceful pregnancy and delivery, after the terrible trauma of last time, is more important (which is a VERY valid way to feel about it) then an elective c-section is a safe and reasonable option too.

One thing that did strike me is that in everything i've found about perineal body length studies, while a short perineum has no effect on the risk of tearing, cutting an episiotomy into a short perineum is VERY likely to cause severe damage and two studies i read suggested that cutting such a perineum, unless the baby is in severe emergency distress, is clinically inexcuseable. It's clear if you cut a 2cm epi into a 6cm perineum you've created a 1st-2nd degree injury, but if you cut that into mine it'd be a 3rd-4th degree.

One study i just found had a few sentences in it stating that faecal incontinence 6months post-partum was NOT found to be associated more with vaginal delivery - women who had c-sections suffered at the same rate. Perhaps you could get a referral to a urology/gynae to talk about strategies for that as a (sort of) seperate issue?

Bx

Thanks Hoobley i totally agrre with everything you said and was very close to tears when i read your post, i truly would love to have a natural birth to be honest i wouldnt want a home birth but would be open to water etc. (too scary after my sons situation) My other "fight" i see if i do choose that option is family and friends i was out for dinner with them all last night and they mentioned recovery after CS and how they would help and i said i wasnt totally decided on that at the moment, well you can only imagine the barrage the " why on earth would i do that to myself again" etc. etc. my DH doesnt even want to discuss it (prob something to do with the inability to have sex for almost a year after ds) any way im still determined and if i have all the info we will see im not closed to it. I have actually thought cause my ob said if i go early i can try a VB, i might say she can book me in for a CS at 39.5 weeks if i go before that i want natural and if its a big bub or after that then i will agree to the CS, or something to that effect. Either way i will be in control :dance: thanks Hoobley.