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?

Yes a lot more reasearch needs doing as we don’t yet fully understand it.

Respiratory distress syndrome can be transient but it can be much more severe and potentially (although rarely) fatal also. We don’t want to scare women who are recommended to have an elective caserean for other medical reasons with this information when it’s so rare but it is a risk. The same as risks for vaginal birth or instrumental delivery, if you listed every single risk we’d have women terrified of pregnancy! So you have to discuss it in the context of how likely it really is and what would happen if it occurred and rare complications of every risk factor and even rare complications of treating the rare complication. You’d be there all day if you tried to give women ALL the information so it’s cherry picked to what is relavant in each situation.

This is a good study if you’re interested in RDS occurance in ELCS. It also explains why elective caesareans are now done later (around 39 weeks) even though 37 weeks is classed as term. Unless of course other risk factors are present meaning baby is better out than in as in your case.

www.ncbi.nlm.nih.gov/m/pubmed/20021786/

Thanks Catching, that's interesting as I specifically asked the consultant if the breathing risk could be serious, and she said very categorically it would only be transient, though might require a short stay in the NICU.

Maybe she was trying not to worry me any more than I already was, having just been told my DD would need to arrive three weeks before we expected.

I’m sure she was trying not to worry you but it’s wrong to answer an outright question with misinformation. While it’s rare to be serious, especially as I assume you had antenatal steroids, it does happen and it’s not impossible for even term babies to have serious breathing problems and lengthy neonatal stays. Obviously pre-term babies are at higher risk but elective caesareans are now done later as babies born at 37-38 weeks were showing higher rates of RDS.

I agree it was a disingenuous answer. I didn't have steroids, we did discuss it but on balance decided not to, which the consultant said she agreed with.

And if your DD had IUGR than there was probably much higher risk of not delivering her and the complications from that than there was of RDS, it’s all about balancing the risks and trying to follow the course of action that leads to the most likely best outcome.

"High forceps are often used instead of a caesarean a) because it’s quicker and depending on the reason for the forceps being needed seconds could count. b) because assuming no complications it’s a quicker recovery for Mum and c) it means mum has a high chance of a normal vaginal delivery next time and doesn’t limit the number of children she has like a caesarean can do."

This is so awful.

Most women don't want more than three children (the "healthy/advised" limit for cesareans). What on earth can the rationale be for trying to avoid c-section unless the woman has specifically said that she wants a bit family? Who is making theses decisions? I'm getting flashbacks of the Irish medical establishment and the awful symphysiotomy debacle.

Quicker recovery? Hahahahahaha. Not from the stories I have heard. I had a CS and it was not easy to recover, but I'd rather that than sitting on a doughnut cushion for weeks and then having a bunch of surgeries to try to fix my bust pelvic floor over the next few years.

The vast majority of forceps deliveries are uncomplicated and recovery is quick, you can’t compare complicated forceps with uncomplicated caesarean accurately. Additionally you state 3 Caesarean sections are safe, however the risks associated with them actually increase with every single one you one, there isn’t a safe limit. Some have 4 and are fine and other have major complications with a second. As discussed earlier decisisons are made quickly on what is likely to lead to the best outcome for both Mum and baby, sometimes that decisison is wrong.

www.dailymail.co.uk/femail/article-4863610/The-natural-childbirth-myth-NATASHA-PEARLMAN.html
This article, by the editor of Grazia, is worth a read if you haven't already. I'm glad somebody with more of a platform than the average woman has taken the time to speak up. It was originally in The Times but republished here in the DM

@rubyeliza There is some inaccuracies in that article though. Morphine isn’t given during labour, there isn’t a 24 window to deliver baby in if your waters break, the guidelines say START the induction after 24 hours and at 2cm dilated you are not in labour so she didn’t have a 30 odd hour labour, that’s the latent phase which can stop and start for days. Research proves that women in the latent phase of labour progress quicker into active labour if at home in their own comfortable surroundings, that’s why we send you home and tell you to come back later, reasearch proves it leads to better outcomes for women.

During my second labour the baby's heart rate briefly dropped and an emergency team came into the room. The doctor in charge quickly asked my DH if there was anything we weren't willing to consent to when deciding a plan of action. My DH immediately said 'Absolutely no rotational forceps' and they had to take this choice into account and go along with it.
I had carefully read the risks during pregnancy and made the informed decision that I would way rather risk an EMCS than keillands forceps. My DH, as my birthing partner and therefore advocate, was very aware of this and knew to speak up should the situation arise whilst I was in too much pain to properly think and communicate.
As mentioned, in labour and particularly emergencies, it can be difficult to properly talk through risks and options, which is why it's so important for women to be as informed as possible beforehand. I was able to have that element of control by a) reading up during pregnancy and b) having a birth partner who was willing to help me communicate my wishes and preferences. So I disagree that all women will just go along with whatever is recommended to them once they're in labour because all they care about is getting the baby out.

@CatchingBabies I don't think everyone will agree with everything in the article but I think she makes some strong points. Particularly that nowadays women have careers and expect to be able to return to them without being physically and mentally altered. Also that men certainly wouldn't put up with what women are expected to.

She certainly does make some valid points yes.

As a midwife I would say you are in the minority having researched options eg. Rotational forceps, prior to labour and having decided that you would not consent. The majority of women don’t do this and when the doctor says baby is in trouble and needs to be born now, forceps are the quickest way of doing that. The majority consent. Wether or not that is enough to be deemed full informed consent is another matter but in true emergency situations it’s not always easy to ensure you are providing that either.

This discussion has been very interesting though and has certainly given me a lot to think about in my practice regarding the way risks are communicated to women.

I agree I'm in the minority and it shouldn't be that way. I hope women are encouraged more and more to know their options and be more involved in decision-making in their own labours and births. Like I said, prior research and a decent birth partner who will advocate are a couple of ways to ensure more control at a vulnerable time. There ARE ways to ensure better informed consent even with the obstacles of emergency situations and labour pain.

I agree, and antenatal education needs improving and standardising to improve this education as well. Like many aspects of the NHS there seems to be a defianate postcode lottery on the standard of care you receive.

Regarding consent for high forceps - in the trials I work in, you would not be complying with the law in the situation above - because the patient has to be counselled on risks before starting the drug or whatever. To get them to a certain point then say ‘we need to do x and x is safest’ would be illegal.

I think there is little comeback for hcps if informed consent hasn’t been obtained. So realistically is it that important to hcps to ensure the woman is giving informed consent. ‘As long as babies ok’ is the phrase that springs to mind.

Pressed send too soon earlier - the point is that a woman in pain and in danger mid labour is extremely vulnerable. She has no way of truly consenting because the information presented to her is not balanced and she’s in a vulnerable position. The doctor telling her that this is the safest way (and it isn’t always, many countries don’t have high rotational forceps due to the damage they do) is loaded information, under pressure, after the point she should have been informed, to a vulnerable patient. She cannot truly consent. She is in effect being forced.

In a trial, if you were in an analogous situation, the patient could sue for that. And they would win. And your trial would be crucified by the regulatory bodies. Vulnerable patient groups have extra protections.

Really the only way such a patient can consent is if she has been told before the onset of labour and the usual ‘x can go wrong, in that case we do x or x - for these reasons, these are the risks and benefits. If you are in that situation what are your wishes?’

This to me is one reason PND rates are so high - women are actually suffering from PTSD are traumatic deliveries. People can dea with a lot of trauma, what’s often more damaging is the feeling of not being part of the process, the helplessness of having things done TO you rather than a choice you made previously.

It cannot be impossible to run through the most common scenarios quickly before a birth. Very rare complications aren’t needed - but things like forceps etc absolutely should be.

@Badoc have you read the post properly?? Being older whilst does have risks doesn’t pre-dispose you to vaginal injury 🙄🙄🙄, what do you think you me vag disintergrates between the ages of 25 and 35!!

These things have always happened vaginal injury has nothing to do with age and isn’t exclusive to things like gestational diabetes. The problem is no one talks about which unfortunately leaves a void for missinformation, like lots of things to do with fertility, pregnancy and child birth.

I think age is a factor actually - I was reading something last week that I’m sure said the risk of levator ani muscle being detached from the pelvis increases with age...

The data I’ve seen seems to show that planned section is safer for the baby and riskier for the mother.

@CatchingBabies sorry but a C section is generally more expensive than a vaginal delivery, (hubby and I do demand and capacity modelling/planning amongst other things for NHS), you’ve got the use of the theatre for a start, although in some hospitals assisted deliveries will be done in theatre then there’s the cost of the anaesthetist and also follow care, and whilst most consultants don’t care (in my experience) and will do what’s best for the paretient, they are all very, very much aware of how much things cost maybe not down to the exact £ but they will know one option versus another and you could never rule out that this doesn’t impact decision making.

@carlitamurray32
sorry but a C section is generally more expensive than a vaginal delivery
Out of interest does this include medium and long terms costs associated with both or just the actual costs of delivery?

That’s interesting Carlita - does the modelling take into account lifetime costs?

So say (figures firmly pulled out of arse for demonstrative purposes...) a c costs 8k and a VB costs 2k.

So, ten women forced into VBAC, appears to save 60k. But then 40% of those women need emcs and longer hospital stay and more complications. And 40% of the rest who do VBAC will require instrumental delivery, and most of them will need care down the line. Plus morbidity and future surgical repair due to prolapse etc. Plus trauma, therapy, future incontinence repair etc etc. Lots of those costs are bourne by general medicine. And I can imagine that once they’re added in, the cost gap for the lifetime Is much lower.

Someone upthread said NICE has been costing it out and the overall increase of a c is 87 quid. I don’t have a reference for that but it seems fairly reasonable given the above.

@Bowlofbabelfisg Totally agree, I think so many women

@Carlitamurray32 Are there any studies or modelling in the NHS that takes into account the cost CS versus the cost of aftercare and follow up surgeries where women have suffered injuries in childbirth?