3rd degree Tear

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3rd degree Tear

3rd degree Tear
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Hello All,

A mother in one of my classes had a 3rd degree tear during birth and was asking me if there were Yoga practices she could do to help it heal. Does anyone have ideas on this? My main idea so far was reverse breathing.

Thank you,

Andrea

Filed under: '3rd degree tear' 'third degree tear' tear
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Fri, Aug 5 2011 7:07 AM In reply to
francoisef

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Hello Andrea, A third degree tear is quite serious. Perhaps Vanessa Hodge, our midwife adviser, can advise on what the current guidelines are given to midwives regarding 3rd degree tears. My understanding is that there can be different sorts of 3rd degree tears, but that they involve laceration of the pelvic diaphragm and perhaps tearing of the central tendon and even the risk of fistula? It would be helpful to know more about this particular tear. Reverse breathing would be fine but it should be done in restorative positions. For tears, supported Badhakonasana, quite raised, works well. Also Viparita Karani with legs against the wall. And possibly all four positions, legs comfortably apart according to where the tear has extended. Lots of glutes work and general full yogic breathing with a gentle uddhyana bandha I'll think about this more, this is what I can come up with right now. It's important to repair tears well. They are getting more common and give a bad name to 'normal births' . Women who want to try a vaginal delivery after a 2nd or 3rd degree tear feel vulnerable and frightened and they are easily convinced that it's better to have a section. All best and thanks for raising this important issue, I hope that other people pick up this thread, particularly midwives Francoise.
Francoise
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Fri, Aug 5 2011 8:56 AM In reply to
chris

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Hi Andrea,

As a retired midwife I have come across various tears following vaginal deliveries

Doctors often describe 4 types of tears whereas midwives tend to only describe 3 types of tears

1st degree perineal skin only is torn.

2nd degree perineal muscle and skin is torn

3rd degree perineal muscle and skin is torn to the margin of the anal sphinctor but does not involve the sphinctor itself

4th degree involves the whole of the anal sphinctor.

I have run yogacise ( Birthing Lightly ) classes and had mums who have had previous 3rd degree tears. With good preparation, using yoga positions and effective yoga breathing during next delivery they have gone on to have normal deliveries with minimal tearing or in two cases I can remember have had intact perineums. Really important that they keep their bowels regular following delivery and during next pregnancy to avoid unnecessary strain on perineal muscles.

As Francoise says it would be interesting to know more about this woman's tear and more about her delivery and how the tear occurred.

Bye for now

Chris

Chris Johnston
Phone: 01245 352373
Email: chris.johnston@blueyonder.co.uk
Web site: Birthlight classes in Chelmsford
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Mon, Aug 8 2011 8:53 AM In reply to
andrea

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Dear Françoise & Chris,
Very many thanks for your helpful replies . I have now written to this mother to see what else I can find out about this particular tear & will also see her again this week. I do know it is coming up for 12 weeks since the birth & causes her pain & discomfort still.

I was wondering, Chris, how midwives categories tears since you say they use one less category than Doctors?

Thanks so much again.
Andrea
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Mon, Aug 8 2011 11:18 AM In reply to
chris

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Hi Andrea,

The 1st and 2nd degree tears are the same.

The 3rd degree that midwives used to describe was down to the anal margin and the sphinctor itself . However having not worked as a midwife for the last 10 years it may be that they are now also describing 4 types similar to the mediacl staff.

Bye for now

Chris

Chris Johnston
Phone: 01245 352373
Email: chris.johnston@blueyonder.co.uk
Web site: Birthlight classes in Chelmsford
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Mon, Aug 8 2011 3:15 PM In reply to
Wendy

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Hi Chris,

Are you able to share more about the Yoga practices and breathing techniques that you found most helpful? I also had an advanced 2nd degree tear (almost to the anal sphincter) with my first baby and I am pregnant again - I healed well but know that there is probably still some scar restriction there that doesn't bother me in daily life but does concern me a little as I wouldn't want to have to go through surgical repair/epidural process after an otherwise wonderful birth as it had major impact on our early postnatal experience. I found the reverse breathing very helpful and did it little and often (particularly when feeding) but I would be keen to know more about your experience with teaching as I am currently learning the Birthlight approach.

Hi Andrea - I don't know if your lady can access any acupuncture but I was able to have one session with a fantastic acupuncturist and completely felt the affected area reconnect during the treatment which was quite profound and I think, together with the Yoga practice, really enhanced my healing process. I am also a Women's Health Physio and it is really important that she heals well and regains good strength for long term pelvic floor health/sexual function/continence etc. I had a home birth with hospital based midwives and the hospital I was linked to automatically had 6 week reviews with a specialist Women's Health physio to check the strength/endurance of the pelvic floor muscles for women with though this isn't automatic for 2nd degree tears at every hospital. However, it is standard practice for women to be referred for Women's health physio review for a 3rd degree tear as it can severely affect continence through damage to the anal sphincter/cause fistulas etc. as Francoise highlighted. Your lady would benefit from this If this hasn't already been arranged - sometimes people something slip through the referral cracks. If it hasn't happened, it would be worth her speaking to her GP and getting a referral as it is something far better to deal with earlier than later. It is important that she maintains good hydration, avoids constipation etc. also for the healing process as well to preserve pelvic floor function for the future.

Whilst many Physios still teach standard kegel pelvic floor exercises and not the Birthlight approach with the activation of different parts of the pelvic floor as well as reverse breathing ( I wish more WH physios were trained in the birthlight reverse approach!), it would still be beneficial for her to have someone check what she is actually doing with her pelvic floor as even basic correction, combined with following the Birthlight approach that you are able to teach, can have a profound effect. Over the years,I have found many women think they are doing pelvic floor lifts but are bearing down or gripping, using their superficial pelvic floor muscles and not the deeper ones, which isn't helpful - it can make them give up thinking there isn't any point in doing them and if they are bearing down, can certainly make the problem worse.

Best wishes,

Wendy

Filed under: '3rd degree tear' 'third degree tear' tear, continence. incontinence, pelvic Floor
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Thu, Aug 11 2011 1:07 PM In reply to
vjkhodge

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Hi Andrea

As a practising midwife (11 years) on a busy Labour Ward, I have seen my fair share of 3rd degree tears and unfortunately some 4th degree tears too.

What causes them? There are several theories, but as far as I know, current research tells us that most 3rd degree tears occur as a result of an extended episiotomy (usually by a doctor performing an instrumental vaginal delivery). This makes us feel far better about the whole horrible business as midwives!

Tears are categorised as:

1st degree - involving skin only

2nd degree - involving skin and muscle (i.e. pelvic floor)

These two are the most commonly occurring tears.

3rd degree - involving the anal mucosa - these are then further categorised into 3a, 3b, 3c (depending on severity)

4th degree - involving the whole anal sphincter

Primary repair of 3rd and 4th degree tears in of paramount importance, so only skilled Obstetric Specialist Registrars or Consultants should suture these.If the primary repair is not successful, secondary repair has a poor success rate.

Women having big babies, with a history of previous 3rd or 4th degree tears, instrumental deliveries, difficult births eg shoulder dystocia deliveries are at risk.

Healing takes many months from a third or 4th degree tear, so I am not surprised to hear that this lady is still suffering pain at 12 weeks. It also takes time to retrain the anal sphincter muscle as the nerve supply has been damaged and takes many months to reconnect and therefore have good function.

I myself suffered a 3a 3rd degree tear as a result of an emergency 'lift out' forceps with episiotomy for fetal distress in 2nd stage of labour. As is often the case when in lithotomy, this led to a shoulder dystocia and a subsequent 3rd degree tear. A pretty typical scenario for a midwife having her own baby!

At my 6 week postnatal appointment my routine exam by my obstetric consultant involved a finger in the anus and being asked to clench it! He felt nothing. I had some intensive physio and by 3 months could clench his finger! (I have to face this man every day at work!) I found reverse breathing initially and then a variety of pelvic floor exercises were what helped. They had to be done in every position - sitting, lying prone, lying on my side and later squatting most helpful. It is no good being able to control your anal sphincter only when sitting but not when standing. The greatest challenge for my pelvic floor healing was being able to practice and feel control in a deep squat. So I would certainly give your client this advice. Practice fast twitch and slow twitch pelvic floor exercises in every possible position! Oh and horse riding also helped alot too.

Let me know if you need to know anything more.

Vanessa Hodge

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Fri, Aug 12 2011 6:16 PM In reply to
andrea

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Thank you so much, Wendy & Vanessa, for your helpful posts. I really appreciate your replies especially sharing as you did such difficult personal experiences. They make me realise how many aspects there are to tearing including sometimes trauma associated with postal treatment meant to be healing & restorative.

I now have more information from the mother concerned. M. says (her first language is Spanish, hence some turns of phrase – I thought it clearer to quote her exactly):
“All I know about my tear is:
It's a 3rd degree one which cut through 2 muscles (My baby was 7,12 pounds / 3.5 kg)
I had stitches in theatre with a peridural seconds after my baby was born
I had antibiotics and no infections so far
Every time the midwife or doctor checked it was healing fine
Never put any creams, only bath with lavender and tea tree oil
It was very sore for around 20 days and slowly started to get better
Since I started to do some pelvic floor exercises I can feel the stitches again, it's uncomfortable and sometimes painful so, as you know, I stop doing them

{ During last week’s class, I included a simple Ashwini Mudra, so focussing on the anal area only. She was able to do this without pain, so this seemed a good place for her to start pelvic floor movements.}

I still find it uncomfortable if I sit in the car for too long or if I walk long distances
The birth of my baby was hard, 21 hours labour and no much luck with my midwife (she made me push in the pool for 2 hours only to discover after that I was only 7 cm dilated!) She was very bossy and suggested medical intervention constantly even though it was very clearly explained to her that I wanted the birth of my child as natural as possible.

It wasn't clear why I had the tear, nobody explained to me at the time. Recently I had a complaint meeting at the hospital and all they could say about the tear was that sometimes it's impossible to say why it happens..”

And I extend her thanks to all of you as well:

“Would be great if you help me find ways to heal my tear, thanks a lot for taking the time for this, I really appreciate it.”