Doula TipperarySo you had a perineal tear last time you gave birth. What wre the chances of it happening again?

As a Women’s Health physiotherapist, I meet many of women who experienced severe perineal tears during their baby’s birth.

If you’ve experienced severe perineal trauma during the birth of your baby, you may or may not have got around to thinking about your options if you’re pregnant again or are planning to have another baby.

You’ve got several options to consider – another vaginal birth, a caesarean birth in labour or a scheduled elective caesarean birth. So which is the best option for you?

What is severe perineal trauma?

If you had a large perineal tear during  the birth of your baby, you may have had a 3rd or 4th degree tear.  This is referred to by healthcare professionals as obstetric anal sphincter injury (OASIS) or, increasingly, as severe perineal trauma (SPT). This means the tear extended from your vagina as far as, or into, the anal sphincter (the muscle that controls bowel movements).

Third degree tears are subdivided into 3a, 3b and 3c with 3c being the most severe of the the three. Fourth degree tears are the largest type of perineal tear. Often women have symptoms of decreased bladder and/or bowel control, sometimes for a short time after the birth and sometimes for longer. If you’re not sure whether you had a third or fourth degree tear during your last birth, the best way to find out is to get your birth notes from your hospital. Details of your last birth will be documented there by your care provider.

How should I plan to give birth next time?

There’s no definitive answer to this question. However, there has been some research into whether you’re more likely to have a repeat 3rd or 4th degree tear if you’ve had one before. Here are some of the findings from the research to help you decide the best option for you.

  • The risk of 3rd and 4th degree perineal tears on your first birth varies quite widely depending on what research you look at. A recent large systematic review suggested that it may average around 11% in a hospital setting. Pilates info

  • With regard to the chances of having a recurrent 3rd or 4th degree tear on your next birth, the research again varies. However, the larger and more recent research seems to suggest that having a 3rd or 4th degree tear on your first birth, doesn’t significantly increase the chance of the same thing happening if you opt to have a vaginal birth next time.

  • One very large study which ran from 1967 to 2004 and included 800,000 women found that having a severe perineal tear during a second birth significantly increased the chances of having it on a third birth.

  • Two interesting findings from the same study was that women who gave birth in a private hospital were more likely than those who gave birth in a public hospital to sustain SPT and that those who gave birth in busier hospitals were also more at risk.

  • Several studies found that women who still had bowel leakage arising from severe perineal trauma in a previous birth were more likely to report worsening symptoms after a vaginal birth and two studies recommended elective caesarean birth in this case.

The most recent systematic review (incorporating the best research available at present) published in December 2016 concluded that we really can’t be sure what type of birth is best for women who have had SPT but that “in the absence of higher quality evidence this systematic review and meta-analysis supports the current recommendation of a subsequent vaginal birth for women with previous OASIS who demonstrate no anal incontinence symptoms or sphincter defects.”

Stacking the odds in your favour

If you do decide that you would prefer to have a vaginal

birth, you don’t have to cross your fingers and hope everything goes your way on the day. There are ways you can stack the odds in your favour and reduce the risk of a repeat perineal tear.

  1. Choose your care provider and place of birth carefully. In birth settings with high intervention rates, there is an increased rate of forceps and vacuum use. This is associated with significant increased risk of 3rd and 4th degree tears.

  2. Crunch the numbers. Ask your care provider what the rate of third and fourth degree perineal tears is in his/her hospital and for women under his/her care. Then you’ll have a better idea what your risk is. If you’re not comfortable with the rate of SPT in your chosen place of birth, consider changing to another hospital or consultant whose rate is lower.

  3. Consider a home birth – several studies have found a significantly lower rate of SPT and episiotomy.

  4. Labour in upright positions for as long as you can. Labouring in an upright position decreases your risk of episiotomy (which is strongly associated with increased risk of SPT) by 21%. It also decreases the incidence of foetal heart rate abnormalities (which are associated with increased birth interventions) by 54%.

    There has been disagreement in some of the research as to whether squatting positions or the use of a birth stool leads to more perineal injury and greater blood loss. Overall there’s no firm evidence to support this hypothesis. In fact, the increased blood loss was reported to be associated only with severe tears, of which there were fewer in the squatting positions. I will address this in greater detail in another post.

  5. Consider using a warm compress on the perineum in the second (pushing) stage of labour. This has been shown to decrease perineal trauma.

  6. Practice perineal massage. We know that perineal massage decreases 3rd and 4th degree tears in first time mothers. The same effect hasn’t been shown in women who have given birth before, but ‘breathing your baby down’ or allowing your baby’s head to crown slowly and not pushing at this stage of labour does seem to decrease the chance of a perineal tear significantly. Spontaneous or mother-led pushing has been shown to reduce the incidence of birth interventions, which in turn, may reduce the risk of severe perineal tears.

  7. Write birth preferences. Birth preferences are a great communication tool between you and your care providers and ensure that everyone is on the same page before the birth.

  8. Debrief. If you have any concerns about your next birth or anything you need to address from your last birth, it can help to debrief your previous birth experience with someone knowledgeable. A midwife, doula or birth trauma counsellor may be able to help you with this and prepare for a positive experience this time round.

  9. Consider hiring a doula. There is evidence that having a doula present can reduce birth interventions. It can also increase a woman’s satisfaction with her birth experience.

If you decide to have a caesarean section, you can discuss with your healthcare provider whether you’d like to have a caesarean in labour or an elective caesarean birth. You could also discuss gentle caesarean.

 

Mums’ Stories

ANN, MUM OF TWO

On my first baby I had an episiotomy which extended into a third degree perineal tear. When I became pregnant I was worried that I might have a large tear again. But I birthed my second baby without so much as a scratch and at 8lb 10oz he was bigger than my daughter!

JUDITH, MUM OF TWO

After having a severe third degree perineal tear during my first birth, I opted to have a caesarean birth this time. The recovery after the caesarean wasn’t easy, especially with a toddler at home. But I felt more comfortable having a planned caesarean, rather than being fearful throughout my pregnancy and labour of having another big tear. It was a relief to forget about the tear and just focus on meeting my baby. I was awake for the surgery and my husband was with me. I had skin to skin and breastfed soon afterwards so it was a really lovely experience for us after all the drama last time.

ORLA, MUM OF THREE

I had a forceps birth and ended up having a fourth degree perineal tear with my second baby. I needed lots of physiotherapy after the birth as a result. Although it took over a year to really feel like myself, I made an excellent recovery. We became pregnant with our third baby four years later. After speaking to my physiotherapist and G.P, I decided to try for a vaginal birth again. I did perineal massage about twice a week from 36 weeks onwards, did birth preferences and birthed on hands and knees on the floor in the birth room. I had a very quick labour (4 hours from start to finish!) and had a small second degree tear afterwards. Thankfully, the recovery this time was much quicker and it was brilliant to feel so much better after the birth.

 

References

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