Weird update

I have removed this post of mine, because it was confusing and not very helpful.

Christine

I'm confused too. When I went searching I found a pub med article that talked about surgery to correct for perineocele that actually shortened the perineum. How weird is that? I guess the distention bulges down so much it makes the perineum measurement much longer? That doesn't seem like what you are dealing with- does it?
So- a rectocele bulges into the vagina- do you not have a bulge in your posterior vaginal wall?
Could I have had a deeper tear that wasn't noticed? YES- 1,000 times YES
Why would a second degree tear cause so much damage? it would not. second degree is pretty superficial-
Is it possible to have another vaginal birth, or is that too risky given the fact that I have little perineum? you can have another vaginal birth- and if you tear more you may end up with a 3rd or 4th degree tear (which from the sound of your perineum -you have already been dealing with).
Can the wholewoman posture and exercises help a perineocele? My guess is yes
Is there anyway to encourage scar tissue to "go away". yes there is- you can work it out.....I can get more details to ya if you can't find anything
And finally is perineoplasty a terrible surgery? you know- I looked into it- because that is what was offered to me after my most recent birth (as in- well we could one day do a perineoplasty....blablabla) and it sounded pretty tough-they have to debride the area- cut into the muscles there-and cut away at the lateral connection of the muscle (where it has retracted) and then they suture it all back together- and all that sounds ok- except then you have a ton of scar tissue there that just breaks down over a long period of time (to paper thin) ....and hurts for a while in the short term. So who knows- if you go for it early in life- and have a great surgeon- maybe a plastics person- it could hold up for a while- but for me- at this time- no way. The area works well enough.
I want a muscle graft :) pretty sure that doesn't exist.

Lyricmama- I hate this for you. I feel so fiercely protective of perineums everywhere- get a good feel around in there is all I can say- and determine for yourself if it is really something that needs fixing.

Lyricmama, you've been around long enough to have probably read our discussion on the importance of preserving the vaginal sphincter, but I thought it important enough to bring up again..

Hi Lyricmama,

I think their evaluation sounds plausible. I also found myself wondering whether you had the straight scoop regarding the status of your “2nd degree” tear. You can feel the old sutures in the perineum as bumpiness.

Sorry about the Red Shoes reference. I just re-read the H.C.Andersen version and didn’t remember that it was such a guilt-trip! What I do remember was the scary old soldier and the girl’s unrelenting dancing in the red shoes until her feet were cut off.

We have been witness to young, postpartum women who just can’t get past the hope that surgery can fix this sort of maternal damage and so off to the surgeon they go...with not such happy endings.

Yet, as Alemama says, it is not black and white and maybe the possibility exists out there that your perineum could be fixed without bringing down your uterus, etc. All we can do is read the literature and keep a sharp eye on the voices of women themselves. It is just good to recognize the complexities of the situation.

We have had a member recently give birth successfully after having had a rectocele repair (which probably included a perineorraphy.) Now that’s hopeful!

Christine

...she planted some seeds that have you worried and that we could take issue with.

Surgical outcomes are better than they used to be? This cannot be substantiated by the current inadequate studies conducted and reported by clinical practitioners, and funded by big pharma.

A *natural* birth could cause more damage? This has not been confirmed by science and is not the experience of several of our members. In 2004 an editorial appeared in International Urogynecology Journal titled “Informed Consent for Obstetrics Management: A Urogynecologic Perspective.” In the article, G.W. Davila argued for elective cesarean for pregnant women, based on a long laundry list of studies showing pelvic floor damage, pudendal nerve damage, anal sphincter damage, and genital prolapse following vaginal birth. Shortly thereafter, the American College of Obstetricians and Gynecologists created the standard for the practice. Never mind the fact that in none of these studies are the environmental and positional conditions surrounding birth taken into consideration.

What you describe sounds like the perineal bulge and pressure that commonly occur in women who have had rectocele repair. Because of suturing, the natural pathway of intraabdominal pressure is prevented from moving through one area of the vagina, so it blows out another - usually very low in the perineum. I understand that much of your damage occurred somewhat naturally and not through extensive vaginal surgery. Nichols and Randall describe this very process, which I will find and copy here if you like.

Once again, the deeper issues are birth-related and, of course, a political hotbed. In my perfect world we would drastically reduce the number of trained obstetricians and greatly increase the population of midwives qualified to not only assist natural birth, but also diagnose and treat prolapse. I will be writing more about this in the future.

Your anger is perfectly justified - but the problem is really not about the people - it’s about the system.

(((Hugs, Lyricmama)))

Christine

You said:

"The urogyn didn't suggest surgery. She said that surgical outcomes are better than the used to be, but are not great. She did express concern over the state of the perineum and said that there is a hernia there and excessive scar tissue, and that another vaginal birth could cause more damage."

First of all, because of liability concerns, the urogyn MUST warn you that another vaginal birth "could" cause more damage. This is the case all the time, with every birth! But since you've already got a problem, she is covering her legal butt. Lawsuits in the field of obstetrics are way out of control. If you give birth vaginally and get more damage, then you will have an easy lawsuit against her if she did not document the fact that she fully informed you of the risk. What is the REAL risk? Who knows? She's guessing as much as anyone. There are also real risks associated with c-sections. The legal situation however is this: doctors are not sued for "acting" to try to prevent a bad outcome nearly as much as for "not acting". Their risk of lawsuit for you delivering vaginally is much higher than their risk of lawsuit for delivering you by c-section because in the first case they failed to "try" and in the second, they "tried all they could" and unfortunately had a bad outcome anyway. Because of this, depending on how much this urogyn follows what's really right for the patient vs what's legally safest for herself, you might expect when you get pregnant again for her to pressure you to have a c-section. Would that be the right thing for you to do? I've no idea. I can certainly understand your trepidation about another vaginal delivery.

The biggest issue I see with delivering vaginally is how will they handle the perineum? You could homebirth with a midwife who could use all her skill to try to avoid further damage. If you deliver with a doctor I fear they will insist on "prophylactic" episiotomy, and for all we know that will only make everything worse. How can they cut you to prevent damage if they don't know exactly what is going on down there in the first place? On the other hand if you have badly healed "scar tissue" that is more rigid than natural tissue, they may have a point, but personally I'd need a lot of logic to be convinced, ie: somebody who actually seems to know what they're talking about. If you can point out to me a mass on a sonogram and show me how you propose to get around it.... nah, I still wouldn't do it. I'd probably research my midwives extensively and travel if I had to, to get one highly skilled in delivering over intact perineums, and use every (like Christine says) environmental and positional trick in the book to get delivered then let the chips fall where they may. I hate to sound really cynical but I doubt you could do this in any hospital. The pressure to "do something" about your damaged perineum is going to be very strong.

That brings me to her comment that surgical outcomes are better than they used to be. It is true that doctors THINK they're better; the word is out and I've been told this by a couple or three doctors but when I challenge them with the question, "What is the 20 year result of today's leading edge better surgery?" And of course, we don't know, because we aren't 20 years into the future yet; they end up agreeing with my point. However, some gyno surgeons are listening to patients and striving to improve outcomes and doing more conservative better thought out repair procedures. (At least your urogyn admitted they still aren't great. My own gyn went from recommending surgery for me to not recommending it, and I think part of that was that he started waking up and smelling the coffee.) If you must have surgery, the trick is to find those that operate very carefully and conservatively. And even then, Christine is correct, we do not have studies showing that even today's "better" surgical correction of prolapse, is ultimately superior to just leaving it alone. Until I start seeing surgeons use vertical MRIs and publishing their sea change in pelvic support paradigm, I'm remaining skeptical about their "progress".

Now, if in the year 2030, 95% of operated women are ecstatic about their 2010 repairs, I'll happily eat crow, but I'm not going to be one of the guinea pigs.

Thanks for being here with us. I didn't like the way this thread went (my part) and I’m sorry we couldn’t have been more help to you. The “hernia” plus “scar tissue” diagnosis was confusing esp. since that area is comprised of the central tendon (perineal body) and not muscle. I hope you will keep us posted on your progress. Nerve damage to the area often takes several months to heal and may be contributing to the sense of heaviness and pressure. (((hugs)))

When I had my first baby I tore very badly. My midwife coached extensively (probably because this was my first baby...and probably also because she ran an international midwifery school and there were a dozen midwives-in-training watching my birth) and after I tore she stitched and stitched and stitched for a good while. She would not tell me what kind of damage there was or how many stitches I needed. (That was back when I was still shy. Today I would demand to know what was going on.) I knew it was bad because afterwords I could not sit up, roll over or walk without incredible pain and pulling in my perineum. It was weeks before I could sit on anything other than a soft sofa. I ended up popping a stitch out, which didn't feel all that great. Not too long afterwords, I was studying my stitches with a mirror and notice a piece of dark red tissue hanging out of my vagina. I went in to see her and she said, "That's part of your hymen still attached. I'll take it off for you." "But," I protested. "Why not just leave it alone?" She said, "It'll drive you nuts during sex." So she took some really long scissors to it and snipped it right off. I didn't feel anything. I was miserable for a long time trying to heal the stitched area. The pain was absolutely incredible.

I felt instinctively like there was no good reason for all that happened. Any time after that when I ran into another mommy that midwife had delivered, I asked if she tore. All but one said yes, and pretty badly. I began to suspect something. 1, this was a pretty high "rip rate" for someone who had delivered 12,000 babies. 2, maybe she allowed it to happen because she needed to show her students how to repair tears. I began to get a little angry.

Fastforward two years. I decided NOT to use that midwife the next time around. I met another midwife through the La Leche League and described to her what had happened. It turns out she had been trained by the first midwife. She said, "Who did the stitches? She herself or one of the students?" I answered that it had been the midwife herself. "Then I can tell you with certainty that you had at least 20 stitches. Any less than that and she would have gotten a student to do it."

I don't know how you can fit 20 stitches in the space of a little perineum, which means there must have been some pretty deep tearing and she had to do multiple layers of stitches inside. Maybe somebody here can shed some light on that for me.

So anyway, she said I had some extensive scarring inside my vagina. I had complained to her about pain, and she ran her finger along the scar inside. It still hurt nearly two years after the first delivery.

But I am delighted to tell you, Lyricmama, that I successfully delivered a 10 lb 5 oz baby in less than 5 hours and only tore enough to need one stitch. I talked her out of giving me that one stitch because I tended to be a little tight in the vagina and I welcomed the extra space it would afford me (er..uh..the extra space it would afford DH). LOL

My third baby was born with very minimal tearing, and with my fourth I had no tearing at all--only significant prolapse. *sigh, sigh, sigh*

I bet that if you give birth in a squat or on your hands and knees, you can avoid problems.

Olive oil and vitamin E are great for healing scar tissue. If you regularly rub either or both into the perineum, it will loosen up, especially if you do it in the weeks prior to the birth.