Considering Natural Birth After Anal Fissure: A Mother's Dilemma

Anal fissure issues?

Hello Dr.
Chen, I live in Europe and I am currently 36 weeks pregnant.
Today I went to the hospital for a check-up, and my baby currently weighs 3400g with a head circumference of 35 cm.
For my first child in February 2014, I had a natural delivery, but the baby was born with a large head circumference (37 cm), which caused a tear to my anus.
Three months postpartum, I followed up with a colorectal specialist who advised that for my second child, I should definitely have a cesarean section.
However, today my obstetrician believes I can attempt a natural delivery but also cautioned me that my baby is on the larger side.
I am very hesitant; I want to try for a natural delivery, but I am afraid of tearing again.
In March 2015, I was diagnosed with grade II hemorrhoids, and I scheduled a resection for the end of April.
Now that I am pregnant, my belly is quite large, and I have developed new polyps.
Can I attempt a natural delivery? Thank you.

Mrs. Peng, 30~39 year old female. Ask Date: 2016/06/21

Dr. Chen Jiaming reply Surgery

You might want to share your concerns with your obstetrician, as a colorectal surgeon would typically recommend a cesarean section to avoid the risk of perineal tears during a subsequent delivery.
This recommendation also considers that the scar tissue from previous tears is less elastic than the original tissue, which indeed increases the risk of re-injury.
However, for an experienced obstetrician, this being your second delivery means that the birth canal is likely to be more accommodating than during your first delivery.
Generally, with the implementation of a prophylactic episiotomy during vaginal delivery (which can be repaired and sutured afterward), you can successfully complete the delivery with a lower risk of complications involving tears extending to the anus.
It is important for your obstetrician to understand your fears and anxieties, as they can help reassure you with their expertise and experience.
(Since you are in Europe, medical practices may vary, so it is advisable to ask questions for clarification!)

Reply Date: 2016/06/21

More Info

When considering the choice between natural birth and cesarean delivery, especially in the context of a previous anal fissure and the size of the baby, it is essential to weigh the risks and benefits carefully. Your situation is complex, and it is understandable that you feel torn between the desire for a natural birth and the fear of complications.

First, it is important to acknowledge that both natural birth and cesarean delivery come with their own sets of risks. Natural birth can lead to complications such as tearing, especially if the baby is larger than average, as you experienced with your first child. An anal fissure can be exacerbated by the pressure and trauma of delivery, particularly if the baby’s head circumference is significant. On the other hand, cesarean delivery, while often seen as a safer alternative in cases like yours, carries its own risks, including infection, longer recovery time, and potential complications in future pregnancies.

Given that your first delivery resulted in an anal fissure, it is crucial to discuss this history with your healthcare provider. Your obstetrician's opinion that you can attempt a natural birth may be based on the fact that many women with similar histories have successfully delivered vaginally without complications. However, the size of your baby, currently estimated at 3400 grams (approximately 7.5 pounds), is a factor that cannot be overlooked. Larger babies can increase the likelihood of tearing and other complications during delivery.

It is also worth considering the advice of the rectal specialist who recommended a cesarean for your second child. This recommendation may stem from a concern about the risk of re-injury to the anal area, especially if you have had previous issues with fissures and hemorrhoids. The presence of new polyps and the history of internal hemorrhoids further complicate the situation, as these conditions can be aggravated by the strain of labor.

In terms of communication with your healthcare team, it is vital to express your concerns clearly. You might want to ask your obstetrician about the specific risks associated with a natural birth given your history and the size of your baby. Inquire about the possibility of a controlled delivery, such as using an epidural to manage pain and reduce the urge to push too forcefully, which could help mitigate the risk of tearing.

Additionally, consider discussing the option of a planned cesarean delivery with your doctor. While it may not be your first choice, it could provide peace of mind knowing that you are taking steps to protect your health and well-being.
Ultimately, the decision should be made collaboratively with your healthcare providers, taking into account your medical history, the size of your baby, and your personal preferences. It is essential to feel comfortable and supported in your choice, whether that leads you to opt for a natural birth or a cesarean delivery. Remember, the goal is to ensure a safe delivery for both you and your baby, and there is no one-size-fits-all answer in this situation.

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