Need some delivery thoughts - protecting perinium at all costs!

[meganne79]

Hi mamas,
I need some suggestions/advise about delivery. I am delivering in a hospital with a CNM whom I love and trust 100%. Homebirth is not an option for me as no homebirth midwife will come near me LOL.

I have developed a huge vericose vein that runs right through my perinium (think bigger than your little finger). My midwife is absolutely not recommending a section because of it but I do need to "think about" a few options.

I had what I think was a necessary episiotomy with ODD (was tearing through my urethra rather than down and she wasn't close to being out yet) and also had one with YDD as I was again tearing up and she was stuck. Her shoulder dystocia did result in nerve damage so she needed to come out quickly.

Obviously an episiotomy is absolutely not an option with this delivery. I don't "want" one but it makes me nervious that it is not an option. YDD was stuck and she was only 7lbs, 11oz. Obviously since I tore up in both cases I don't have the strongest tissue there and now my perinium is weak from being cut twice.

My midwife gave me a couple options to think about. The first being having an epidural and letting the baby passively descend. I would have to have the epidural turned up pretty high so I don't push at all. This would allow everything to stretch to the max super slowly to hopefully avoid tears through the vein. I was not planning on using any medications during delivery though so I don't know what to think.

Another option is to have a natural labor and "hope" everything turns out ok (i.e. I don't rupture the vein nor tear through other vital parts like my urethra!). This option scares me a bit because of my history. Extreme blood loss terrifies me beyond any form of reason. I lost 3500cc after ODD was born and it took me 4 transfusions and 6 months to feel recovered. Rupturing a vein that big (though it is rare) would result in a pretty substantial loss of blood not to mention another delivery ending in trauma. I still deal with PTSD related to ODDs delivery. I also have a low-lying placenta to contend with so there is already the possibility of having a larger than normal blood loss. They keep an OR ready and blood products in the room for me already (history has a nasty way of repeating itself) but I am not sure how I would handle the emotional trauma.

Last option, and not one I am really even considering, is a section.

Sorry this is so long, I just feel a bit lost. Obviously I'm pretty darn familiar with the birth process and lean much more toward the low intervention side but I have an already traumatic birth history personally to contend with.

Thank you!

[cali4niachef]

I have some varicose veins that are good size that run through the back of my RT leg and RT labia.

I would HIGHLY encourage you to treat them prenatally. Its really quite easy. Varicose veins pose no effects on your actual labor or birth.
There are several herbs, supplements and homeopathic options used to treat varicose veins.
How many wks are you?

I drink an herbal infusion (tea steeped for 4hrs) with Nettle, Butchers Broom Root and Oak Bark Root (also some other herbs). Those three herbs aid in vascular support by strengthening veins and nettle is great for circulation. I drink a quart a day.

I also take 500mg of Rutin with 1,000mg of Vit C with bioflavonoids daily. Start out by taking 250mg for a week of Rutin and then move up to 500mg. This is EXCELLENT for varicose veins.

I also take the homeopathic Lycopodum 30c, twice a day.

When I drink my herbal infusion and take my Rutin w/ vit C daily I notice a HUGE difference in the varicose vein.

I have to say I'm highly concerned your MW had not encouraged you to treat the varicose vein prenatally and she thinks it would affect your birth.

Also tearing depends tremendously on fetal presentation, maternal nutrition ( a diet with good fat creates elasticity), coached pushing vs. body directed and maternal position. Having an epidural GREATLY increases the chance for a malpositioned baby, coached pushing and the bad maternal positioning thus causing more damage to the perineum. Suggesting an epidural is EXTREMELY counterproductive to avoid tearing.

As for shoulder dystocia its most common in average sized babies, using the Gaskin Maneuver is the best technique to resolve it. But if you have an epidural and aren’t mobile throughout labor you increase your chances for SD

What is your hemoglobin? What are you doing to build up your blood supply? If your hemoglobin is greater(12-15) this gives you more blood stores to work with incase you do PPH. What was your hemoglobin at your last birth?

I think the advice your midwife has given you is quite uninformed and has the potential to do a lot more damage.

Originally Posted by meganne79 Hi mamas, I need some suggestions/advise about delivery. I am delivering in a hospital with a CNM whom I love and trust 100%. Homebirth is not an option for me as no homebirth midwife will come near me LOL. I have developed a huge vericose vein that runs right through my perinium (think bigger than your little finger). My midwife is absolutely not recommending a section because of it but I do need to "think about" a few options. I had what I think was a necessary episiotomy with ODD (was tearing through my urethra rather than down and she wasn't close to being out yet) and also had one with YDD as I was again tearing up and she was stuck. Her shoulder dystocia did result in nerve damage so she needed to come out quickly. Obviously an episiotomy is absolutely not an option with this delivery. I don't "want" one but it makes me nervious that it is not an option. YDD was stuck and she was only 7lbs, 11oz. Obviously since I tore up in both cases I don't have the strongest tissue there and now my perinium is weak from being cut twice. My midwife gave me a couple options to think about. The first being having an epidural and letting the baby passively descend. I would have to have the epidural turned up pretty high so I don't push at all. This would allow everything to stretch to the max super slowly to hopefully avoid tears through the vein. I was not planning on using any medications during delivery though so I don't know what to think. Another option is to have a natural labor and "hope" everything turns out ok (i.e. I don't rupture the vein nor tear through other vital parts like my urethra!). This option scares me a bit because of my history. Extreme blood loss terrifies me beyond any form of reason. I lost 3500cc after ODD was born and it took me 4 transfusions and 6 months to feel recovered. Rupturing a vein that big (though it is rare) would result in a pretty substantial loss of blood not to mention another delivery ending in trauma. I still deal with PTSD related to ODDs delivery. I also have a low-lying placenta to contend with so there is already the possibility of having a larger than normal blood loss. They keep an OR ready and blood products in the room for me already (history has a nasty way of repeating itself) but I am not sure how I would handle the emotional trauma. Last option, and not one I am really even considering, is a section. Sorry this is so long, I just feel a bit lost. Obviously I'm pretty darn familiar with the birth process and lean much more toward the low intervention side but I have an already traumatic birth history personally to contend with. Thank you!

[hpfgirl]

Originally Posted by cali4niachef I have some varicose veins that are good size that run through the back of my RT leg and RT labia. I would HIGHLY encourage you to treat them prenatally. Its really quite easy. Varicose veins pose no effects on your actual labor or birth. There are several herbs, supplements and homeopathic options used to treat varicose veins. How many wks are you? I drink an herbal infusion (tea steeped for 4hrs) with Nettle, Butchers Broom Root and Oak Bark Root (also some other herbs). Those three herbs aid in vascular support by strengthening veins and nettle is great for circulation. I drink a quart a day. I also take 500mg of Rutin with 1,000mg of Vit C with bioflavonoids daily. Start out by taking 250mg for a week of Rutin and then move up to 500mg. This is EXCELLENT for varicose veins. I also take the homeopathic Lycopodum 30c, twice a day. When I drink my herbal infusion and take my Rutin w/ vit C daily I notice a HUGE difference in the varicose vein. I have to say I'm highly concerned your MW had not encouraged you to treat the varicose vein prenatally and she thinks it would affect your birth. Also tearing depends tremendously on fetal presentation, maternal nutrition ( a diet with good fat creates elasticity), coached pushing vs. body directed and maternal position. Having an epidural GREATLY increases the chance for a malpositioned baby, coached pushing and the bad maternal positioning thus causing more damage to the perineum. Suggesting an epidural is EXTREMELY counterproductive to avoid tearing. As for shoulder dystocia its most common in average sized babies, using the Gaskin Maneuver is the best technique to resolve it. But if you have an epidural and aren’t mobile throughout labor you increase your chances for SD What is your hemoglobin? What are you doing to build up your blood supply? If your hemoglobin is greater(12-15) this gives you more blood stores to work with incase you do PPH. What was your hemoglobin at your last birth? I think the advice your midwife has given you is quite uninformed and has the potential to do a lot more damage.

I'm so impressed with the mamas on here. This is great advice.

[cali4niachef]

I would also carefully look at your previous births and consider what interventions were used. Was pitocin used or any other meds to augment labor? Was the 3rd stage managed?

Did they rush the placenta? Cut and clamp the cord before it was done pulsating? Pull on the cord? Etc.

These all have the potential to cause more blood loss than what is normal.

[yeah-tongith]

I'm sorry you are stuck between a real rock and a hard place.

Are there any options that result in the passive descent of the baby without using the epidural? I'm thinking... hypnosis perhaps? And maybe something more substantial than just hypnobabies... something that could really put you in a state of passivity. Maybe I'm talking science fiction here or something!

Or, is waterbirth an option? This could not only help the perineum, but probably relax you quite well. Perhaps even a combo of these--hypnosis (of some sort or another) and water during the pushing phase.

If was in your place, and there weren't options for naturally increasing relaxation during birth, I might just go with the epidural. One of the positives I can think of with that option is pain relief in the (sounds like rare) event that the vein does rupture. I'm not sure what they would do to treat it, but if it involves any surgical procedures, at least there is no "wait time" for pain relief.

I'm sure you've already thought of this, but... are there any ways to actually treat the vein beforehand? Are there any specialists you could consult with?

I really hope some good options become available to you, and that your birth goes smoothly!

[ArtyMtnMama]

Saying a prayer for you! I don't have much advice to give. You probably already know that a water birth can reduce tears. If that an option at your hospital? Even in a standard tub? Also try visualization. Imagine as vividly and frequently the type of L&D you want to have. Imagine all the details, what your midwife says and does, how you feel, etc.

[meganne79]

Originally Posted by cali4niachef I would also carefully look at your previous births and consider what interventions were used. Was pitocin used or any other meds to augment labor? Was the 3rd stage managed? Did they rush the placenta? Cut and clamp the cord before it was done pulsating? Pull on the cord? Etc. These all have the potential to cause more blood loss than what is normal.

Oh I've been over it a million and a half times with multiple perinatologists. I had an undiagnoesd accreta that resulted in a completely inverted uterus. There was no active management of the third stage, my uterus just inverted and delivered with the placenta when I pushed. Yes, I know how rare that is. Lucky me gets to be a "rare" statistic for practitioners to cite now. They were able to manually reinvert my uterus after giving me nitro but that took several minutes and as I'm sure you know, there was no way to slow the bleeding in that timeframe.

[meganne79]

Originally Posted by cali4niachef I have some varicose veins that are good size that run through the back of my RT leg and RT labia. I would HIGHLY encourage you to treat them prenatally. Its really quite easy. Varicose veins pose no effects on your actual labor or birth. There are several herbs, supplements and homeopathic options used to treat varicose veins. How many wks are you? I drink an herbal infusion (tea steeped for 4hrs) with Nettle, Butchers Broom Root and Oak Bark Root (also some other herbs). Those three herbs aid in vascular support by strengthening veins and nettle is great for circulation. I drink a quart a day. I also take 500mg of Rutin with 1,000mg of Vit C with bioflavonoids daily. Start out by taking 250mg for a week of Rutin and then move up to 500mg. This is EXCELLENT for varicose veins. I also take the homeopathic Lycopodum 30c, twice a day. When I drink my herbal infusion and take my Rutin w/ vit C daily I notice a HUGE difference in the varicose vein. I have to say I'm highly concerned your MW had not encouraged you to treat the varicose vein prenatally and she thinks it would affect your birth. Also tearing depends tremendously on fetal presentation, maternal nutrition ( a diet with good fat creates elasticity), coached pushing vs. body directed and maternal position. Having an epidural GREATLY increases the chance for a malpositioned baby, coached pushing and the bad maternal positioning thus causing more damage to the perineum. Suggesting an epidural is EXTREMELY counterproductive to avoid tearing. As for shoulder dystocia its most common in average sized babies, using the Gaskin Maneuver is the best technique to resolve it. But if you have an epidural and aren’t mobile throughout labor you increase your chances for SD What is your hemoglobin? What are you doing to build up your blood supply? If your hemoglobin is greater(12-15) this gives you more blood stores to work with incase you do PPH. What was your hemoglobin at your last birth? I think the advice your midwife has given you is quite uninformed and has the potential to do a lot more damage.

I'm 31 weeks. My hemoglobin is 12. With my first it was 13 before and last time it was 12 as well.

I know most veins are not a problem in delivery (I've seen some horrible ones, and never seen them pose any issue). The location of mine is why I am concerned as it runs right through probably the weakest part of my body right now.

[songbird516]

What positions did you give birth in the last two times? The same position? It's possible that the shape of your pelvis is such that tearing will inevitably happen in the same place, but it's hard to know that without knowing the positions that you gave birth in last time. Are your providers worried about accreta again?

[meganne79]

Originally Posted by songbird516 What positions did you give birth in the last two times? The same position? It's possible that the shape of your pelvis is such that tearing will inevitably happen in the same place, but it's hard to know that without knowing the positions that you gave birth in last time. Are your providers worried about accreta again?

The first I was on my back (it was my choice, I was unmedicated and it was how I was most comfortable). Second delivery was side-lying (sort of! I was tired so I was closer to my back but my pelvis was not totally flat), also my choice. The are pretty flexible about pushing position, those where how I was most comfortable. I know they aren't ideal but I was not pushing well upright or on all fours.

Yes, there is some concern about accreta again because it statistically does reoccur but is very difficult to diagnose prenatally. There haven't been any obvious signs on ultrasound yet but that is why they will have an OR and blood ready. They did the same thing with YDD and I didn't need it. Luckly my placenta is completely anterior and low-lying this time. With my accreta it was all fundal so at least we know it is not in the same spot this time. I have a final u/s to check again at 36 weeks. If all looks good still we will just assume it will be fine but be prepared.