Childbirth injury risks

[BackInTime]

A discussion among friends about our childbirth experiences has made me think that not enough information is given to women about the possibility of injuries and long term problems as a result of a vaginal delivery. Almost all of us have ongoing incontinence, some had bad tears and one has had a prolapse needing surgery. These things are impacting women’s lives years after giving birth. It seems to be a hidden problem with many women suffering in silence.

AIBU to think that women need to be more informed about risks of a vaginal delivery especially in situations where there’s a high risk of injury like with a big baby?

Some of the scenarios being discussed are complex emergency situations in which a junior obstetrician may not know the right thing to do!

For all pregnant women to be fully prepared for making completely informed evidence based decisions about every scenario (apparently including cord prolapse at 25 weeks!) would involve training all pregnant women to the level of obstetric consultant. Even then it is different when you are the patient, when you are in pain, when you are frightened. Consent is important but professionals aren't encyclopaedias for dispensing information. They have experience and judgment and they should use this to direct patients appropriately (not to violate them obviously! But to direct them and to explain and to suggest, sometimes strongly, the best course of action is part of the role).

Yes, antenatal care and information giving could (and should) be much better in the UK.

But it's important to realise that fully preparing someone for every emergency scenario is not possible. Noone expects this level of preparation or consent if they are involved in a car accident and could die within minutes. Sometimes you have to place your trust in an expert.

Also, considering someone's future fertility is not misogynist for pete's sake! Any more than trying to save a patient's leg is ableist. Can anyone really say they would want their obstetrician to perform a hysterectomy at the drop of a hat, because "for all they know I've completed my family". You cannot expect a distressed severely unwell woman facing the death of her baby to have a discussion about the statistical likelihood of hysterectomy from emergency CS at 25 weeks whilst you make and carry out a technically difficult plan within mere minutes and the weight of a dying baby on your hands. By necessity, explanation and consent in these circumstances is going to be simplified. Sometimes "I think your baby is in immediate danger, I think your baby is going to do very poorly, I need to deliver as soon as possible, I'm going to do" plan a", because I think it's the fastest and best course of action, I will consider "plan b" if I have to but its more dangerous for you than "plan a" at the moment" is the very best communication that can take place in a terrible situation.

this thread has made me so sad and angry. I insisted on an ECS and refused an induction because I was so fucking terrified of a vaginal birth after induction and the increased risk of intervention. I don't regret that for a minute after reading this thread.

I don’t think it’s about giving women loads of info and expecting them to become obstetricians over night. I think the obstetricians are usually good about talking to their patients appropriately. I do however think there needs to be some honesty in society about birth injuries. We talk about cs risks but no one mentions the vaginal delivery issues and the long term continence issues linked with certain types of delivery. This isn’t about doctors talking to us it’s about women being honest with other women when talking about these topics

I agree Summerthunder - there is a huge difference between preparing for every possible eventuality and being reasonably realistic and honest with women. The number of women experiencing some sort of birthing injury isn't a minute percentage, it's high!

For me, I think part of the problem is that when women have done some research/gained some knowledge they are often dismissed which has the impact of destroying the trust with their caregivers. If I can't trust you to have an honest conversation with me which acknowledges the risks of VB (for example) when I'm completely calm and not labouring, then how can I trust you to follow my wishes, consult me properly or even treat me respectfully when I'm labouring.

NB I know plenty of caregivers are respectful etc - but this approach damages trust.

Summerthunder I completely agree there is a societal problem. Its like it has to be sanitised into something beautiful and perfect, or on the flip side have juvenile and sexist jokes about it or treated as something too disgusting to talk about. Don't hear enough realistic conversations. It's the lack of openness that prevents us, as a society, from prioritising birth injury the way it should be prioritised.

@shrimpi

Thank you, you summed up what I was trying to say regarding consent much clearer than I managed x

If I can't trust you to have an honest conversation with me which acknowledges the risks of VB (for example) when I'm completely calm and not labouring, then how can I trust you to follow my wishes, consult me properly or even treat me respectfully when I'm labouring.

I agree with this.

Nobody has said doctors need to educate women in their care to consultant level and i think that's rather insulting to all the women here who have given account of all the ways in which their concerns have been ignored or belittled by medical staff in a variety of situations. What doctors and midwives need to do is unbiasedly give facts pertinent to ALL the options open to the woman and support her in making her own choices.

Shrimpi I said the fact that women aren’t consulted about their preferences, and prioritising that they may want a bigger family as a reason for using forceps over cs is wrong. I said nothing about not attempting to preserve fertility and a consultant doing a hysterectomy at the drop of a hat, you made that bit up. It is not even comparable as a hysterectomy can also have far more implications for health than just fertility.

My point being, for example, a women is having her second child, and needs high rotational forceps or c section to get the baby out, and no one has asked if she has a preference, (which is virtually the case for every woman giving birth on the nhs that I have spoken to). So say high rotational forceps are used, with part of the rationale being, it will spare her the scar on her womb, reducing the risk of complications in future pregnancies and meaning she should be able to birth vaginally again.

However these forceps will lead to episiotomy, increased chance of a very serious tear, increased chance of urinary and feceal incontinence, increased risk of prolapse (that may require surgery at a later date).
This same women may be confident that her family is complete. The risks of cs may have been far more acceptable to her, had they ever been explained, with potential consequences for future pregnancy as a result of cs being virtually inconsequential to her because her family is complete. She may have preferred the cs. It may have been far better for her health. But it wasn’t deemed worthwhile enough to educate her during her pregnancy, so she could be part of the decision in labour.
She may just have been told, “we need to get baby out, we will give you a cut and these spoons will help move the baby into the right position”. How is with holding information from people about their health ok?

It seems to be reductionist and yes a mysogonistic view that potential future childbearing could be used as a rationale for an intervention that could impact on a women’s health for the rest of her life, when the doctor doesn’t even know that she wants more children.

Can you imagine if a men gave birth, “we are just going to cut your penis now and use these metal instruments to guide baby out”. He then spent the rest of his life with his pelvic organs hanging down, incontinent when he excercised, and a negative impact on his sex life. It would have happened once and never again. Men just wouldn’t stand for other men having their genitalia butchered without their consent.

There would be choices, there would be more information.
But this isn’t the case. Women give birth. until they start making a fuss about it, and more attention is given to birth injuries, birth trauma, and the paternalistic attitude of the nhs, as well as the diabolical aftercare in some areas, sadly, it will continue.

In my area, we don't even DO high forceps anymore. It's a straight C-section at that point.

@Readytotalk

My point is that giving facts on "all" the options is.. What do you mean by all? Every possible scenario? In advance? Because that is beyond what's possible, even in the best resourced system.

There are some emergencies that are so unpredictable and decisions that are very situational and difficult that have to be made in the moment. That's all I'm trying to say. We understand this about the rest of emergency medical practice. It's also true of obstetrics. I think as much as there needs to be openness about birth injury, there needs to be openness about sometimes an instrument is what's going to save your baby's brain. And in that moment it's not going to be possible to make a calm calculated decision or have a lengthy discussion about it (however, this is quite apart from ignoring people's expressed advanced wishes and not communicating with them like human beings or being rude or being violent!)

However, completely agree that there should be way more information on basics, common scenarios, common injuries, procedures etc. This is lacking. We don't talk about it enough.

However, I would argue that this is fundamentally a resource problem. Women, unless high risk (and even then) have minimal antenatal appointments and majority won't even see an obstetrician at all before giving birth. We would have to employ many more obstetricians and midwives to improve antenatal education to an ideal level.

Whereas I feel there is an emphasis on professionals having some kind of attitude problem in this thread (and I'm not trying to doubt that some of them do! Nor that there are still systemic issues about the way that women's bodies are regarded. Nor have I read every post here!) I'm trying to balance that with a mention of the literal time constraint on having these discussions antenatally and also the vast breadth of obstetrics which I think people are being a bit unfair about (eg "how could an obstetrician try to deliver vaginally at 4cm dilated!?" when they know nothing about the complexities of dealing with cord prolapse at 25 weeks, because obstetricians exist for a reason. That's not trying to be personal about one person because I understand why they would make that statement.)

I just wanted voice something, a particular view or agenda I guess. Without trying to make it more important or true than what other people have voiced. Just a counterpoint. Does that make sense?

To declare my bias I attend deliveries as a paediatrician and I have seen many many deliveries but I am not an obstetrician and there is an awful lot about obstetrics I don't know. Probably because of my job the complications that affect babies are going to be those that stick in my mind most.

Fair enough shrimpi your insight is interesting.
Likewise a colorectal surgeon would probably have particular views of childbirth, if the only part of childbirth they see is dealing with the aftermath of horrific injuries.
I do get that without forceps and ventouse, some babies wouldn’t make it. No one would want that.
But where choice is possible, in 2018, the woman should be granted that dignity in my opinion. I do think some (certainly not all) hcps don’t see any problem in with holding information either, there may not even be a bad motivation for this, believing that they know best. But women’s priorities for their health and quality of life are all different. For many womem having better pelvic floor health may be a very good trade off for not having that third baby because of cs scars. But no one has ever asked her.
If some places manage without high rotational forceps at all, then everywhere should be able to give women a choice of what happens to their body (and indeed their baby).
I know this is contraversial, but I believe cost comes into the decision making aswell, and the cheaper option of forceps is bound to seem more attractive than surgery and possible longer hospital stay etc.

@ithinkididmagic

I think we have crossed wires as I was focused on a particular example, and you are speaking more generally.

What I'm trying to say is, cord prolapse in premature labour at 25 weeks is an unpredictable emergency. Women can't all be prepared for it, they can't all be counselled on it, it is one of thousands of possible emergencies. Its an obstetrician's job to be prepared for it. And in that situation, it is not imo remotely unreasonable to consider a woman's ability to have children in future, as something of probable importance to that woman, particularly where the fetus has a very limited chance of survival. In fact, its the obstetrician's job to consider it. From the sounds of things the obstetrician made the wrong decision. I don't think the wrongness of it is because she was being misogynistic, or lazy. Probably because she was shit scared and panicking and made a mistake. Consent isn't the main focus of that case. It's about a medical professional making a mistake in a dire emergency.

We have to think what the headline story would be if an obstetrician carries out an emergency section on a dead baby and then performs an hysterectomy on a young first time mum (because em CS on a 25 week womb is much more dangerous) who will now never have another baby. Why did she "choose" the dead baby? People would ask.

Or what the headline about the obstetrician who decided the baby had probably died, so decided to wait out a natural vaginal delivery, and then the baby was surprisingly born alive and profoundly brain damaged. Why didn't she act? People would say.

I'm trying to say some scenarios are really, really difficult.

However, if you were talking about a situation with more time (a woman with several days until she gives birth prematurely) then completely, every option that is reasonably likely to crop up should be discussed. Different delivery options, the risks, her preferences. Of course. I'm saying this isn't always possible in a dire emergency and there are many of those in obstetrics. Worse, it is difficult sometimes clinically to know the difference between a dire emergency and a situation that is probably okay. Dealing with this uncertainty and communicating it is hugely challenging.

By the time you come to high rotational forceps vs CS you are dealing with at least a potential developing emergency. The obstetrician may have a strong feeling based on their experience, and that particular situation that one is best. However, I do agree with you completely, that to every extent possible within the constraints of that situation that informed consent should be obtained. Where fully informed consent is going to cost too much time, at least a sensitive explanation of what the hell is actually happening and why! I'm sure this doesn't always happen and could be improved. Advanced discussions do make this a lot easier but there it is back to the resource problem.

Actually I do think that if somehow penis cutting was involved these decisions would still be complex and difficult. I don't think birth injury can be prevented 100% in any world, because childbirth by its nature is risky. Injuries caused by caesarian section are also birth injuries. If every woman gave birth by elective section then more women would die, for a start.

Nor does a disastrous injury occur with every instrumental birth. Sometimes they are a very quick and effective way to deliver a baby. Sometimes an instrumental is a better choice by far than an unnecessary CS - but its going to be hugely different in individual women and situations. And sometimes there will be more time to discuss options there and then than at other times.

I couldn't agree more with you about improving our openness about it, antenatal information and also postnatal care. I do agree also society doesn't treat this with the importance that it should because it affects women and because childbirth is regarded as "natural", "normal" and as though, if you try hard enough nothing can go wrong (a blame and shame culture basically, for those with injuries). However, I guess I'm trying to say, not every instrumental carried out as an emergency is an abuse.

I should probably take back "if every woman gave birth by emergency CS then more women would die" as I guess that's not an experiment that's been attempted so that may well not be true? I fairer thing to say would be, caesarian section comes with its problems too and isn't an childbirth panathea.

If I am trying to have a chat with a patient (or usually in my case parent ) about different options, I try to explain pros and cons, rationale etc but will often (unless there really isn't one) give my recommendation or "what I think I would choose". I want them to be able to make their own decision (within reason because in paediatrics we would have to consider child's best interests if a parent wanted to make a clearly harmful or dangerous choice), but I don't want to to abandon them to it, because it's my job to guide as well as inform.

In a way if patients received no direction and just made their own decisions then in one way that would be great for doctors as they would be less responsible when a decision turns out to end badly! If a patient doesn't follow my recommendation, and I've written the necessary backside-covering essay in the notes, then if that results in a bad outcome then obviously I'm going to be upset but professionally I'm in the clear. It's when the doctor makes a recommendation that is followed, or takes a course of action on their own because they think that's what they must do in that situation - and then it all goes wrong, that the doctor is not safe professionally.

So in a way, on those rare occasions, where I am really urging someone, because I am really really worried about the consequences of their decision, that I am sticking my neck out the farthest. And at other times, you think you know best, and it's important to step back and think "do I really? Am I being flexible enough?" and you reconsider. Doctors are humans.

I have refrained from commenting about the poor prem baby who was decapitated because I realise this was a very rare and complex case and media reporting on the case is likely to be less than accuate.

I am speaking generally about ante natal, post natal care and women’s decision making involvement. You make a good point that more women would die if there were more elcs. Im far from an expert but know that there are other risks with cs aswell like a higher chance of a heavy bleed requiring a hysterectomy. Babies apparently have a higher chance of being fat as adults and having asthma if they are born by cs, according to some research.
But then of course elcs would eliminate the risk of a perineal tear, surely it would also eliminate many risks to the baby, like shoulder dystocia.
So my general point is, unlike emergency medicine, where no one can predict when you might need an a and e doctor, there is months of awareness that a women will have a baby. So why can’t she choose which set of risks she is more comfortable with.
Risks of a vaginal birth are never generally discussed with women, in my experience anyway and going off virtually everyone on this thread. It does seem like it is like the holy grail to give birth naturally from my experience. In an ante natal class I attended a midwife spoke negatively about a women who ‘bailed and wanted an epidural’. So many of these things must contribute to pnd

I’m sure if men gave birth, it would still be complicated, but I don’t believe they would be as disempowered as some pregnant and labouring women are, with often very little choice about what happens to them. When things did go wrong I believe a Mans complaints that his sex life was damaged would be taken more seriously.
I do think it speaks volumes about the way society views women and their role, in the way they are treated post Natally.
Generally speaking, nhs are very quick to say yes, incontience can be a problem for some women particularly after vaginal birth, but there are lots of treatments for this.
But sadly to get these treatments on the nhs, there are plenty stories of women on here having to hound their gp for physio referrals etc, and the services are so inaccessible, they just give up and life with their problems.
The irony is, nhs will probably have to sort many of them out with a prolapse repair when they hit menopause, if not before.

I fully take your point, that some instrumental births may not be awful. I wouldn’t refuse if forceps was the only option to get my baby out alive. But often it isn’t, I have heard of women being cut, the forceps failing, only for them to have to do a cs anyway. So a cs must have always been a potential option. But there was no discussion. I feel like where choice is possible, I.e situation of high forceps or cs, regardless of expert knowledge, my body is my own and I would like to decide what happens to it. The only way I can decide is if I have information about the risks of each. But because this isn’t something that’s routinely discussed in a non biased way, I suppose like everyone else, I will just have to hope that the person with the power makes decisions that I’m happy with.

Shrimpi you do sound flexible with your patients.

I guess that much of this paternalistic attitude I think there is in obstetrics, is due to the fact that vb is inevitable without intervention and considered the default.

There is also the aspect of mental health which I believe is not highly prioritised, but could very much be considered a birth injury. I have read some research recently that of a women requests an elcs and is refused, she will be much more likely to have PTSD. How sad for these women and how sad for their newborns.

I do think that women are talking about issues like prolapse more and more and they are less likely to put up with troubling symptoms. Maybe better post natal care would pay for itself eventually....

Thank you. This has been an interesting discussion (I really have to go to bed now). I agree with much of what you have said especially re importance society places on women's sexual health and availability of adequate postnatal care.

The irony of this debate is that I am much more often in the position of defending CS as it can have a very bad reputation amongst some groups of people (eg people who are super pro natural birth)! Have seen many lovely CSs.

The only thing I have left to say (and I didn't realise it either until I saw it) is that (although surely less likely) shoulder dystocia and prolonged, difficult extraction can still happen with CS. If the baby is large or breech then the space they are operating is still relatively small and tight and the uterus may be contracting. Even with elective CS, though CS is always easier and safer when not in labour.

Any way, night night.

I do think that women are talking about issues like prolapse more and more

I’m fighting for a repeat cs at the moment and I think I have found data that shows this. It’s in Swedish, and it’s the latest from socialstyresten ‘Komplikationer efter
förlossning: Riskfaktorer för bristningar, samt direkta och långsiktiga komplikationer’

There’s a table on risk of anal sphincter injuries that shows that they are more common in women with higher education. Now after we’d had a chuckle about rarified arses, DH and I discussed that, because we are both scientists, and we know that when you get a result like that, it’s generally necausevthe higher the education level, the less crap women put up with, the more likely they are to complain etc.
And that means if you think about it that all the other rates are probably under reported.

Anyway, tucked right at the end in appendix three of that report is a table that shows thirty year outcomes. The highest incidence of complications is for women who have had BOTH vaginal and cs births.

Incidentally, when he was reading this and helping me translate, DHs main observation was that ‘why on earth isn’t there more data on this?’ To which the reply was ‘because it’s womens health love, no one gives a fuck.’

prolonged, difficult extraction can still happen with CS.

True in my case. Ds did NOT want to come out, there ere operating around a placenta previa with vasa previa so I presume their field was limited. They almost resorted to ventouse but he popped out in time although I did need the incision extended and I lost a fair amount of blood.

I would still prefer a second section to a VB. to me the difference is a more defined risk level, higher than an easy VB yes, but avoiding the truly awful complications that can occur in VB. seeing how well the team in theatre dealt with the complications during section and comparingvthat to the chaos that has been friends VB when stuff went wrong....

What do the thread experts think of the Odon device's potential as an alternative for forceps?

@Ithinkididmagic

No woman should be being “cut” for a forceps delivery and then going to a Caesarean section, unless it’s a twin delivery of course. The episiotomy to deliver via forceps should not be performed until the head is virtually crowing, once it’s crowning it’s only coming out one way. The episiotomy shouldn’t be performed earlier as it’s not beneficial so no one should ever have had an episiotomy and then failed forceps. That’s bad practice and certainly not the norm!

I also don’t believe that cost does come into it. An uncomplicated Caesarean section isn’t that much more expensive than an instrumental delivery, particularly if there are complications as a result of that. Plus the people making the decisisons to go for instrumental or surgical have no input into finances, it isn’t there job to worry about that they just provide the care so there would be absolutely no incentive to them to save money even if it did save the NHS money.

@shrimpi Elective Caesarean sections are safer for the mother but for the baby it’s actually better for them to have experienced labour prior to the Caesarean as it lowers the rates of respiratory distress syndrome. Obviously depending on why an emergency Caesarean has been performed they may have been exposed to other risks but a simple failure to progress EMCS would be safer for the baby than if that woman had never laboured and chose an ELCS.

Catching is the data showing VB to be safer for babies than C sections new? When I had my DD in 2015, the evidence showed the opposite (but c section was slightly more risky for the mother). My consultant agreed that was the case. The breathing risk was there, but overall the risks were lower.

The odon device is currently being trialed so we don’t know how well it works until following the trial. However it’s being recommended as an alternative for LOW forceps in non- emergency situations so it certainly wouldn’t be a full replacement of forceps.

@shovingleopard It’s difficult to compare as Caesarean increases some risks for baby and lowers others and vaginal birth vice versa. It’s unique depending on the individual risk factors, some babies are safer being delivered by Caesarean etc.

There also havnt been any up to date studies comparing outcomes as it’s not ethical to test. What we do know is that babies born by Caesarean are more at risk of lowered immunity and allergies, asthma etc. The theory is that babies immune systems are “seeded” during vaginal birth and this doesn’t happen with Caesarean sections.

If comparing elective caesarean than assuming no other risk factors vaginal birth is safer for baby as not going through labour increases the risk of respiratory distress syndrome, this is because the fluid in the lungs isn’t squeezed out the same way and they havnt laboured so havnt started the preperations for life outside the uterus. In that aspect emergency caesarean is safer than elective, however the fact that it’s emergency means there may be other risk factors that cancel out the reduction of respiratory distress syndrome, unless the Caesarean is for failure to progress etc. rather than a fetal issue.

It really is different for every case and that’s why it can be so hard to make decisisons as to recommended method of birth for women.

Thanks Catching my consultant was of the opinion that the breathing issue would, if a problem, be transient only. As it turned out my DD had no issues whatsoever, and had an apgar score of 9, which was a relief as she was only 37 weeks, and had IUGR.

The seeding thing is the one issue I was unsure about when I chose ELCS. I wondered about whether I should try and seed the baby, but decided not to in case of nasties like group B strep. Interestingly, I saw a study reported in the newspapers a few days ago that showed no benefit to trying to self-seed c section babies, and in fact mentioned dangers. I can't remember the size of the study, mind you. I suspect we have a way to go yet in teasing out the role of the microbiome, its role in many aspects of health, and how to manipulate it to our advantage.