question

first, good for you for getting to know whats going on firsthand. you will become the expert on your body, and that will prove to be an invaluable resource. you will learn to know what's helping, what's hurting, how to help yourself heal. its a good thing.

I don't think my posterior tear was third degree. its not all the way to the anus. and I have a rectocele (asymptomatic, by the way). I, too, was told - by THREE different health care providers - that I didn't tear. but I know better. I can SEE the scar tissue. I can see where the tissue (skin and also another layer, I'm assuming muscle) is no longer in one piece. I can FEEL when I kegel, that the muscles seem not to be anchored in the right places and the contractions are wonky. and worst of all, I have the wierdest sensation when that area is touched, I call it 'pain in the brain'. it doesn't hurt physically, but my mind is screaming that it hurts. very odd.

now, I'm not sure that more stitching up will do much in terms of rectocele improvement. looong time ago, when I first got here, I posted that question. there was another woman conteplating having her tears surgically redone. we both chickened out. first of all, I'm afraid of surgery. period. second, I don't feel confident that a surgeon will ***really*** be able to control him/herself and leave the rest alone (kinda like picking up the socks but leaving the underwear under the bed). and third, I'm afraid of scar tissue and nerve damage. I can live quite well the way I am, scared of the unknown potential ill effects of any surgery. a bird in the hand, I say.

that said, I still get upset when I think about how nobody thought to properly tend to my postpartum perineum. maybe that's another reason I'm loathe to entrust it to anyone with a scalpel.

Hi Katie,

I did have a 3rd degree tear (to the anus) with my firstborn, but wasn't aware of any prolapse until after my 2nd. The doctor who delivered my second baby told me it was a little bit of "skid marks" (isn't that a nice image?) but a nurse later looked at my chart and said it was a 2nd degree tear. That one went off to the side a little and not straight back.

My understanding is that a posterior tear may increase risk for rectocele, but is not a necessary precondition. I hope someone will correct me if I am wrong.

Both of my tears were posterior but I have a much more prominent cystocele than rectocele. My MD wasn't even sure there was a rectocele when she last examined me (sadly, it has since made its presence more apparent.)

As for stitching up - I *think* you could see scar tissue without having had stitches if it was a superficial tear, that didn't go down into the muscle. I read somewhere that they don't always stitch those up. Again, hope someone will correct me if I'm wrong.

I complained to my first OB about the obnoxious skin flap around my anus when I went for a regular GYN visit and she said maybe when I had my next baby, if I got an epidural that time, she could redo some things. Then she went on to say it is really hard to stitch someone up well when they don't have an epidural. I still trusted her at the time, but I was starting to get pretty irritated at all the things she blamed on my not having gotten an epidural (that would be a whole other post, though!).

I drew the following conclusions after some thought: (a) Obviously she didn't stitch me up that well, since she was admitting to it herself, (b) my symptoms were not actually related to the superficial issue of my slightly deformed anus, (c) I would much rather try not to tear at all than let her do another episiotomy just to "get it right" the second time, and (d) if my symptoms were related to how the deeper tears were repaired, then I wouldn't risk having that redone and ending up worse, given that my symptoms were pretty tolerable.

Hope that made sense.

I have also heard that sewing up properly is a lot harder than it sounds, which is why many midwives will leave minor tears alone because they seem to heal naturally better than when a doctor tries to piece things back together.

Good luck,
Sarah

what you wrote all makes sense to me

as far as I know, oftentimes superficial tears are left to heal on their own. its a judgement call and is probably a good topic of conversation to have when shopping for an ob. not for guarantees or anything, but to see where their philosophy lays.

my scar is in a V shape, about an inch long. not one straight line. so the edges of the torn tissues scarred independently. they were obviously torn apart and never knit back together on their own.

and I really hate that 'blame the patient' type of comment. why is an epidural better for proper stitching than a local anesthetic?

I believe my doctor thought that patients who have an epidural are calmer and she can take her time more without worrying about administering more and more local and never quite numbing everything. (The anal area just didn't take the local very well; she said that was common.) I was very traumatized from the birth experience and freaked out by the seemingly endless stitching. But I do believe part of a doctor's job is to deal with patients who are not currently their best selves, and I certainly wasn't uncooperative, so I don't see why she couldn't do just as good a job. Well, you know from my "anger" post that I've got some issues, so I'll stop here ;)

this comes from Christine's blog-

I leave the final words to Michel Odent, M.D:

“I have never had to repair the perineum after a real undisturbed foetus ejection reflex. One of the many reasons probably is that in such a context the mother is more often than not bending forward, for example, on hands and knees. In such postures, the mechanism of vulva opening is different from that of other postures. First the anterior part of the vulva opens more quickly; then the deflexion of the head tends to be delayed and, when the face is coming out, the chin is more lateral. I use this opportunity to mention that, if by chance there is a benign tear (usually because there has been no authentic foetus ejection reflex) I do not stitch it. If the mother does not spread her legs at all during the first two weeks (avoiding looking at the perineum, avoiding the lotus posture, etc) the cicatrisation will be perfect.”

And now this is me....
I have had the experience of tearing- then stitching- only to have the stitches pull out. Talk about angry. I did not want the stitches in the first place- actually begged not to have to get them- swore I would keep my legs together for weeks if I needed to- but they forced them on me anyway- and then in less than 24 hours they came out. And it hurts to get them to start with- and I never (in all three times of stitching) got numb.
And then I read about ladies in their 40s and up having episiotomy scar tissue breaking down and that the break down was painful.
So I have decided this time around (IF I even tear- which I surely hope I won't) to just let it be- keep my legs together- and visualize the healing process.
I saw a surgeon at 4 weeks post partum (who didn't even mention the rectocele- but insisted on doing an anal exam to check for a fissure *uh what is that I asked*- in retrospect I know he saw the 'cele which is the reason he checked for a fissure) who told me that I could have the tear fixed after I was done having children. That was after asking me if I planned to have more and when I told him yes.
I don't know what is going to happen at this birth- I have no perineum to speak of- just my anal sphincter hanging on for dear life and if I tear this time I imagine that is the only part left to tear. I have good deep muscle tone and support- but absolutely no superficial support- so I may have someone support that area when the baby crowns.
my tear approximates beautifully- and unless I pull the two sides apart it just looks like a line of scar tissue- but when I pull it apart the rip is deep and extensive.

I know you can have a rectocele with out a tear- women who have never had a baby get rectoceles- chronic constipation is an issue.

I don't think stitching again is going to help- probably all that will happen is the stitched area will feel bad all the time from the pressure of the rectocele bulge-especially if you have a low rectocele.
Kath- I am glad you are checking the area out. It is good to know what you have going on so you can treat it. How is your posture? Are you keeping away from tight clothing? Are you avoiding meat and eating fiber? Those things really helped me.
It does get better. It is actually a really good thing to have both a rectocele and a cystocele. They hold each other up. You may find as one gets better the other gets worse for a time. That was what happened to me. When my cystocele went away my rectocele was more noticeable. But then the rectocele got smaller and I felt great.
Now since I have been pregnant my rectocele has been more noticeable until recently- and I suspect it is because my front wall is softer and is starting to support the rectocele (well or so I think-I have not really looked yet-but that is my guess).

about the keeping your legs together trick.
maybe that would've been helpful in my case.

anyway, I think for me, the goal right now is to accept what is, and figure out how to make the most of it.

alemama- what are you thinking about birth positions? I think the likelihood is that you won't tear anymore.

just wanted to say that I had LOTS of aching perineal pain after my first three births. thought it was normal, even though it lasted about 6 months.
and when my prolapse appeared, it came along with the same aching pain and pressure.
for me, the key was to get off my feet as much as possible. after my fourth birth, I tried to bf laying down as much as possible, but since my baby had a reflux, he did better upright. but in theory, that's what I'd recommend.
and cheese is awful for my system. now that I've been dairy free for quite some time, when I have cheese I can see exactly what it does to me: slows down my digestive system, makes me sluggish and cranky too. so I indulge on occasion, but rarely.
figuring this stuff out on your own takes time. at least it did for me, and I have a bit of background in anatomy. I wonder if a doctor would even be able to tell you with any degree of accuracy, where your fascia is torn. might still be valuable to hear what a specialist has to say, gather all the information you can and then mull it over and see what makes sense to you, what sounds useful.
and remember too, that at 4.5 months postpartum, your body is still healing. it takes time, at least a year, to recover from pg and childbirth.

The pain/pressure while standing up was really unbearable for many months after my first birth. That was the one where I did have a third degree tear, but no obvious prolapse (may have been starting without being enough for me to see). After my 2nd baby with a more minor tear, the pressure wasn't as bad but it was still painful to stay standing for long for at least a couple months. After the first birth, when it was really excruciating, I only had 2 positions - lying flat, or sitting straight up so the pressure was even across my bottom. I couldn't slouch or sit up in bed because it somehow strained my perineum. Breastfeeding was tough. I mostly did it lying down on my side when we were home. Otherwise, lots and lots of pillows to support your back, your baby, your arms, etc.

I did start a program of Kegels (didn't know about WW then!) with a good PT who had me do exercises for inner & outer thighs, glutes, & transverse abs plus the pelvic floor squeezes. While it's possible that time and rest alone helped me heal, I did feel like I saw improvement from the exercises. Particularly because when I had a cough or when I did too many sets and fatigued my muscles, the pressure would return with a vengeance. Sadly the same program never helped the prolapse...

I've heard that a colorectal surgeon can do an ultrasound to check for tears to the muscle inside, and that a lot of women sustain internal muscle injury without it being apparent at the birth. My old OB told me I could see a surgeon for that if I wanted but I refused because I'm always hesitant to see someone who has "surgeon" in their job title ;)

Sarah

Just be a lady of leisure (!). Put the chairs away and use a mattress in the middle of the floor and an assortment of cushions. Lie around a lot, and roll around too, and crawl, instead of getting up to walk, if you have to, or can get away with it! (LOL) If littlies fall off a mattress they don't have far to fall.

Cheers

Louise

when i first came here i remember reading a tip on breastfeeding (maybe it was you granolamom!), to feed sitting on the floor crosslegged with good supportive pillows on your lap to lift the baby up. sitting away from walls keeps you from leaning back. after that i always fed like that or lying down, and it really helped. i'd sit on cushions if i was sore, but tried to keep them quite flat.
but personally, i've always like feeding lying down (i'm lazy, what can i say!)

kiki, don't remember if I posted that but now that you mention it, that's how I bf my youngest. I also prefer to bf lying down but he had a terrible reflux and had to be fed in a more upright position (very annoying during the nighttime feeds)

but as my baby got older I bf on knees and elbows-it was a little hard on my shoulders and neck but great for my prolapse. and had the added bonus of not having to put the baby down if he fell asleep while nursing. I could even do leg lifts.
with my first nursling I could not bf lying down- my boobs just didn't work like that. But by the time I got to the second one I could nurse the kid in the back seat while driving- just throw it right over my shoulder.....

Yay! Alemama! I have once or twice on long drives sat in the back seat, wearing a lap seatbelt, with a baby in the car seat next to me. Yeah, you guessed it. It is possible. That's why those baby seats are cut back at the sides at breast level!! LOL. I am afraid I never did get that "throw it over your shoulder like a regimental soldier, do your boobs hang low?" (Sung to Glory, Glory Hallelujah)

Louise
:-)

wow, alemama, talk about bf olympics. you'd be a gold medalist.
I never would've thought of that position for bf, but imagine...baby falls asleep and you can so easily slip away.