RCOG Advice Update – June 2015

More study updates for you….

The Royal College of Obstetricians and Gynaecologists (RCOG) have just updated their guidelines for management of 3rd and 4th degree tears. The last update was in 2007 so, in light of the study published and discussed in my last post, I think this update was well overdue.

I’m sorry to report that the RCOG knows no more than me about the risks of recurrent severe tears. However, it is very reassuring to see that their advice re episiotomies is up to date (i.e. that an episiotomy brings no benefit in reducing tears unless an instrumental delivery is being carried out). Also, they are quoting studies that reveal the benefits of a warm compress and hands on approach which is very interesting.

The support forums that drew my attention to this new study are skeptical about the RCOG claim that the increased incidence of severe tears in the past ten years relates to better detection rather than poorer quality of care. I’ll let you draw your own conclusions….

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New study

Look everybody! A new study was published last summer of lots and lots of ladies over several years.

It it makes interesting reading. The key conclusion of interest to us was second time rounders have only a 7% chance of a repeat severe tear. Pretty good odds. I worry slightly that some of the ladies with the most severe 3c and 4th tears would have opted for sections and thus skew the results slightly. However, the large numbers involved in the study can provide us with some confidence.

Hurray for confidence!

What Do The Experts Say?

The reason for my carrying out this survey was due to there not being very much publicly available information on recurrence rates.

However, this is the limited information that I’ve found out in my research:

Across the country, 4% of woman with unassisted deliveries suffered a 3rd or 4th degree tear in their first labour in 2011-12. Sucks to be us. In their second labour this figure drops to 1.4%.

Across the country, 6.9% of woman with assisted deliveries suffered a 3rd or 4th degree tear in their first labour in 2011-12. In their second labour this figure drops to 2.5%.

 

My Tips For Avoiding Tears

Based on the results of my survey, I have decided to avoid an ELCS at all costs. There. I’ve said it. Just typing this thought makes me nervous. Will I be too scared to push? Will the hospital be short staff again? Am I even capable of delivering a baby without syntocinon? There are no answers to these questions. However, I’m confident that the risks can be minimised so have compiled a few lists of actions that I will take to avoid a severe tear in the future. The first source of information I’ve relied on is the lovely 50 women who completed my survey….

 

Based on my survey results, I’m certain that I will take the following actions to avoid severe tears in future labour:

(1) Say no to forceps

(2) Say no to induction with hormone drip

(3) I will not push strongly during delivery of the head

Obviously, there may be extreme cases where 1 and 2 can not be avoided but these decisions must certainly not be taken lightly. A well informed birth partner and comprehensive birth plan will be essential.

 

Based on scientific literature, I will take the following actions:

(1) I will not give consent for an episiotomy

(2) I will choose an ELCS if still experiencing severe symptoms from first tear at time of delivery

(3) Prior to labour, I will have a recto-anal scan to determine strength of muscles, extent of scaring and any weak areas that could cause problems

(4) Request the midwife be ‘hands on’ during delivery if circumstances seem right

(5) Listen to my body instead of push when instructed

 

Based on my gut instincts, I will do the following:

(1) Deliver baby with an experienced midwife I can trust who is up to date on the latest research regarding severe tears

(2) Not worry about the size of baby unless excessively large

(3) Ignore any advice given to me about my skin type

 

I’m still undecided on the following points:

(1) Should I have local anaesthetic in perineum again? (pro – would stop me worrying about tearing, con – would stop me worrying about tearing!)

(2) Is the length of my perineum important? (is it worth learning whether mine is normal?)

 

So there you have it. I may come back and add to this post in the future.

What Was Different the Second Time?

After identifying patterns in the birth experience of women’s first labours, my next task was to compare these experiences with what happened during second labours. For the purpose of this task, I ignored women who chose to have an ELCS second time around. Here are my key findings:

 

When comparing second labour with first…

Induced labours dropped from 47% to 23%.

Instrumental deliveries dropped from 34% to 4%.

Episiotomies dropped from 40% to 13%.

Epidurals dropped from 38% to 10%.

Posterior positioned babies decreased slightly from 34% to 13%. 

A second stage lasting more than 1 hour decreased from 64% to 15%.

Women pushing strongly during delivery of head decreased from 74% to 17%, and women panting increased slightly from 11% to 31%. 

3 lucky women were treated to a soothing warm flannel on their perineum, compared with none in their first labour.

Women delivering on their back decreased slightly from 68% to 30%.

Women pushing when they felt they needed to, instead of when they were told to, increased from 20% to 42%. 

 

I suspect that many, if not all, of the above findings will be related to the fact the woman are delivering a baby for the second time and thus their bodies and their minds are more amenable to the process. The factors that I think could be conscious decisions made in a hope to reduce damage to their perineums are the decision on when and how strongly to push, and the choice of delivery position.

Whether the difference is down to a natural or conscious decision is not important though. There are still a number of conclusions that we can draw when examining the birth experience of women who have suffered perineal tears. I will call these my tips for avoiding tears and blog about them another day as it is now my bedtime.

What Went Wrong The First Time?

Survey respondents will know that in addition to asking about what type of tear they experienced and whether they chose an ELCS next time, I also asked 12 extra questions about their birth experiences.

I wanted to find out if there was a clear pattern that linked my survey respondents’ tears to a certain birth experience e.g. inductions or big babies.

Here’s what the results showed….

(1) Instrumental Deliveries

*3rd degree tear but don’t know which category

Woman who had 3c and 4th degree tears had a mostly higher than average rate of instrumental deliveries. Sufferers of 4th degree tears had a particularly high rate of forceps deliveries compared with the national average.

These findings back up the literature which states instrumental deliveries carry a higher rate of 3rd and 4th degree tears due to reduced time for the perineum to stretch.

(2) Induced Labour

*3rd degree tear but don’t know which category

Woman who had severe tears had a higher than average rate of induced labour. Sufferers of 4th degree tears had a particularly high rate of induction with a drip containing the artificial hormone, syntocinon, compared with the national average.

(3) Birth Weight

*3rd degree tear but don’t know which category

A fascinating result. The more severe tears i.e. 3c and 4th were NOT correlated with bigger babies. The less severe tears i.e. 3a and 3b occurred with baby weights closer to the national average.

(4) Episiotomy

*3rd degree tear but don’t know which category

This result must be interpreted carefully. The increased rate of episiotomies associated with more severe tears is most likely linked to instrumental deliveries. Please read this.

(5) Baby Position and Shoulder Dystocia

No clear pattern. Several women did not know the answer and I don’t know the national averages so it is hard to compare.

(6) Use of Epidural and Length of 2nd Stage

No clear pattern and I don’t know the national averages so it is hard to compare.

(7) Position of Mother During Delivery

No clear pattern. Most women were on their backs (70%).

(8) Instruction on When to Push

No clear pattern. Most women were given guidance of some kind either continuously or intermittently (80%).

(9) Mother and Medical Staff Activity During Delivery of Head 

No clear pattern. The only results to note were that all women who suffered a 4th degree tear were either pushing gently or strongly (none were panting), and had staff controlling delivery of the head. No woman reported that she alone was controlling delivery of the head.

 

References

National averages were obtained from the following report:

Patterns of Maternity Care in English NHS Hospitals. 2011-12. Royal College of Obstetricians and Gynaecologists.

At time of writings the 2012/13 data was due for publish in summer 2014.

Correlation Does Not Mean Cause

My next few posts are going to show whether there’s a pattern between type of labour and outcome so this is just a quick post to remind readers that correlation not not mean cause so interpretation with a large pinch of salt is in order. This is particularly true in an amateur study such as mine where number of respondents is relatively low.

So, what exactly to I mean by this? Well, the easiest way to explain is to give a specific example.

One of the questions I asked in my survey was “What position were you in when you baby was delivered?”. I asked this question because we know that some positions (e.g. squatting) create a lot more tension in the perineum than others (e.g all fours) and thus may increase the likelihood of a severe tear. So it is feasible that the results would show a trend whereby upright birthing positions resulted in more trauma to the perineum than recumbent positions where gravity and baby weight are not as influential.

But what if the reason women were in recumbent positions was because they were connected to induction drips? Perhaps it is actually this third factor of inducing labour that is influencing our results? We must therefore err on the side of caution when concluding that birthing position causes severe tears.

In reality, I think the results will be influenced by a large number of factors to varying degrees.  There will most probably also be factors at play not captured by the survey. Please bear this in mind when reading the next posts.

 

What Happened Second Time Around?

My next stop was to analyse whether second experiences were better, the same or worse than the first time. I also looked at the numbers of women that choose to have an elective caesarian section (ELCS) second time around. Lets start with the latter….

Overall, 35% of survey respondents decided to have an ELCS for their second labour. As you might expect, this decision seems to correlate with the severity of tear they experienced in their first labour. 25% of woman who experienced a 3a tear opted for a ELCS second time around. Whereas, 47% and 33% of women who experienced a 3c and 4th degree tears respectively opted for an ELCS second time around. Here’s a graph:

* respondent did not know which category of 3rd degree tear they suffered from

Please note that I use the word correlate above with great caution. Correlation does not mean cause (more on this later) so please interpret this graph with caution. What we can say with certainty though is that most women (65% in fact) went on to have a second vaginal birth. This is very encouraging and I think women worried about what they should do for their second labour should feel empowered by this.

But wait! I hear you say! What if their second labour also resulted in a bad tear? Was it worth it?

Well, this is what the data says for women that went on to have a second vaginal birth…

87% had a better experience second time

11% had the same experience

2% had a worse experience

Here are some graphs that break down these numbers by tear severity…

* respondent did not know which category of 3rd degree tear they suffered from

I think it is worth repeating the statistic above: 87% of women who went on to have a second vaginal birth had a better experience second time. I like those odds!

For the pessimistic readers who are wondering about the 2% that had a worse experience second time, here’s what the woman in question said:

“I don’t think I had fully healed after my first third degree tear so the tear was vulnerable. Plus my baby was 9lb 3 and labour was very quick. (55 minutes from start to finish).”

“I am pleased I tried for a second vaginal birth – luckily after my 4th degree tear, I had a fantastic surgeon who did a great repair and sorted all the problems I’d had first time around. After the 4th degree tear, I had no pain and healed really quickly. I do wonder whether the second tear would have happened had I been repaired properly the first time round, but it was such a relief to be sorted!”

The 11% (or 5 woman) that had the same experience second time around gave the following reasons they thought their tears occurred:

Woman 1:

First labour (3b) – “Quick delivery and hard pushing although not on head delivery”

Second labour (3b) – “Again very quick dilation and labour, apparently poor integrity of skin and due to speed of delivery limited time for stretching!”

Woman 2:

First labour (3c) – “Fast head delivery”

Second labour (3c) – “Previous 3rd degree tear, weak area? Consultant said I only had a 5% chance of tearing again, hence I opted for water birth, however I was that 5%”

Woman 3:

First labour (3a) – No comment

Second labour (3rd) – No comment

Woman 4:

First labour (3rd) – “My daughter came in one contraction. There was no break between head and body.”

Second labour (3rd) – “After being stitched up the doctor said she could tell the area was weak from my previous tear so I think my previous damage caused me to tear again.”

Woman 5:

First labour (3a) – No comment

Second labour (3rd) – “I think it was because I was on my back. The midwife wouldn’t let me move”

 

But this is a happy post so lets end on another positive statistic:

36% of the women that chose a second vaginal birth had NO TEAR whatsoever in their second labour.

 

 

Results Are In!

Here’s a quick overview as I begin the analysis….

74 woman have completed my survey and the graph below summarises the type of tears they suffered during their first labour (blue bars) and then second labour (green bars).

This graph makes me happy. Especially the large bar at the end, labelled ‘None’.

Hopefully, there will be more happy graphs to come.

Collecting Data For My Survey

Perineal Tear Recurrence Survey

Ladies who have had a 3rd or 4th degree tear during childbirth…a little request that might help others.

I had a 3c tear during labour with my first baby and am now agonising over what to do in the future (vaginal birth or elective caesarean section). Would those of you who’ve had a second baby after a 3rd degree tear or 4th degree tear mind filling out my survey? It’s really quick, just yes/no style answers, and completely anonymous.

Tear Recurrence Survey – powered by eSurveysPro.com

I’ve done lots of research into risk factors for perineal tears but couldn’t find much information about recurrence rates so thought I’d do some data collection and analysis. I’m still on maternity leave and need to use my brain!

Once I’ve got a decent number of responses, I’ll post my findings. Might help other women try and make this really tricky decision.

Thanks so much.