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?

The very recent (may 2018) Swedish data - happy to translate any bits of it you want:

www.socialstyrelsen.se/publikationer2018/2018-5-20

Long term follow up data is in appendix 3.

@CatchingBabies if you've had your own babies then, as a midwife, do you feel you get more input and choice when it comes to birth? Or did you fully put yourself in the hands of the staff and go along with their decision-making in labour as most women do? Does your work effect what you yourself are willing or unwilling to consent to?
Just out of general curiosity :)

Is anyone aware of any good stats on birth injury and tears specifically when using low forceps (when baby is low down in birth canal), or indeed ventouse in that same situation?

I am definitely decided on putting non consent to high rotational forceps on my birth plan, but not too sure what the risks are in the above situation.

Is it even possible to specify when you consent to forceps/ventouse and when you don't? And my other question is how would you manage this at the time; I assume you'd need to quiz the HCP wanting to use them on the baby's position? What terminology would you need to use, and what kind of response would you expect?

[quote blacklister]@MNHQ - This thread might be interesting in light of your recent campaign regarding post-natal care. It's very relevant. [/quote]

And thank you @blacklister!

@FluctuatNecMergitur

Here you go Rowan, this is another useful link you can pass on: www.hal.inserm.fr/inserm-00370068/document

Happy to lend my language skills to the cause if it helps.

Brilliant, thank you - I'll pass that on

@Yarnswift

The very recent (may 2018) Swedish data - happy to translate any bits of it you want:

www.socialstyrelsen.se/publikationer2018/2018-5-20

Long term follow up data is in appendix 3.

If you could bear to translate the 30-year outcomes table that would be amazing (I had a try at the summary with Google Translate and I think it got most of it, although there were references to 'emperor' rates - not sure whether that's an actual statistical thing or a Translate error!)

Emperor means c section - they call them kaisersnitt (literally Caesar cut.)

I’ll translate it today or tomorrow for you :)

On litigation costs - one measure being taken by NHS England at the moment is that in order to qualify for a discount on their contributions to the central litigation insurance scheme (NHST Resolution), maternity units have to reach Birth Rate Plus staffing levels (a staffing rate designated as safe and calculated individually for each unit by a specialist team, as I understand it).

Not strictly relevant to the topic, but thought I'd pass it on as it struck me as interesting when I heard it - and when we stand back and look at the bigger picture, it seems likely that staffing rates on maternity units affect lots of the issues being discussed here.

(Disclaimer: as a civilian I'm only half-understanding what I hear in some of these meetings, so it's possible I've mangled this information somewhere, although I don't think I have...)

Here you go RowanMumsnet

Table II. Existence, number and percent of a number of selected complications in relation to women's birth history of childbirth and number of years of follow-up.

(Text down the side)

Women with vaginal births only
Total number of women, N

Urinary incontinence
Fecal Incontinence
Prolapse Surgery
Breaks in the abdominal cavity (ie hernias, I assume this includes diastasis but it’s not clear either here or in the main text, it only refers to hernias.)
Abdominal adhesions

Second row data is the same but for women who have had c sections (kejsarsnitt) only

Third row data the same but for women who have had both.

Interesting that the third group, women who had had both, suffer the most complications. I suppose you’d expect that.

@Yarnswift caesar-cut!

Thank you so much for this, that's brilliant

Also want to thank @CatchingBabies and @Shrimpi, it's so helpful to get a glimpse of how HCPs approach these things and what the limitations are

I had a depressing meeting with my consultant yesterday. He's not sure what else he can do as my body doesn't react well to surgery. I'm being referred back to the physio in the hope that their physio might be able to help. I'm nearly 5 years pp and it's hit me hard that I'm likely going to be in pain and on nerve pain meds for the rest of my life. I'll take that in exchange for my healthy dd, but it's ruined many areas of my life. My poor husband has been wonderful but I really don't know whether we will ever have sex again and I know that we will only ever have one child now. The whole thing is devastating

No!!! And it should!! In a wider context this is part of the problem with the NHS culturally (I’ve found having worked in the corporate world previously), it’s all very much reactive rather than proactive where weighing up costs and benefits are concerned plus people seem to work in Silos. So your Obs consultant will know that in paper roughly what a C Section costs versus a standard vaginal delivery. They will have no idea what the cost of sat follow up Urology care would be on top of a vaginal delivery who had been left incontinent follow injury!! Everything’s treated as separate episodes - which isn’t correct, it will need to change eventually and risk of continuing or follow up care will need to be factored into lots of different conditions and proceedures. But it is a tough sell when it’s so culturally ingrained.

Back to this particular subject my view is we need to talk about it more, so that it’s on our horizon and I think there should be some kind of printed material which could be distributed by midwives with more detail info housed at NHS choices. This could provide the balance between empowering women with more knowledge and not terrifying Is too much. Especially as antenatal classes aren’t compulsory. In the middle of tricky labour is no time to be making an informed decision on anything that been the first time you’ve been presented with the info!! I’m 32 wks at the mo and have been booked in for a ECS for various things, I still have the option of changing my mind but don’t think I will. My close friend who had a really straight forward delivery of an 8lb baby last year (a fit healthy 30 year old) now has to have what she calls a ‘fanny gadget’ after a prolapse, so it’s not even just after an assisted delivery where the risks are.

@Bowlofbabelfish I’ve popped a quick reply on but it didn’t tag properly, have scroll.

@BackInTime I’ve replied but it wouldn’t it hasn’t tagged you!!

@bowlofbabelfish

But where I work women ARE told about the possibility of forceps, ventousse etc. We can’t say there will be a choice between 1 or the other as that depends on the situation at the time. We can’t accuratly give the risks of one or the other as again that depends on the situation at the time. E.g a woman has been pushing for an hour and no progress. The risks of forceps may be higher than the risk of caesarean if the head is still high. A baby’s head is very low and the heart rate suddenly drops or worse stops. A forceps is safer and quicker than a caesarean. The risks of each are totally unique to each and every situation. It is impossible to discuss every single possible situation and the risks of them all. It would require a degree over several years! I could discuss with a woman high forceps vs caesarean and she says no forceps, but if it’s an emergency such as cord prolapse at full dilation where the baby is likely to be dead by the time a caesarean is performed she may feel differently. That’s why consent has to be at the time and unique to the situation that is happening.

You say talk about the common ones, high forceps are only used in 5% of births, is that classed as common? Depends on who you ask. Women should never be having forceps deliveries without pain relief that’s barbaric and is not normal practice. If you genuinely know someone that has happened to they need to complain. Local anaesthetic should always be used for an episiotomy and if doing a forceps delivery the puedendal nerve should also be anaesthesthised.

@rubyeliza I had my children before I was a midwife and I was no more knowledgeable or educated than the majority of mothers. I was happy with my care and was lucky enough to have uncomplicated deliveries. My training since has made me realise that some aspects of my care were bad practice but at the time I didn’t know that and thought it was good. I remember being thankfull for the team that saved my daughters life when she was born with an APGAR of 0. I didn’t realise until after my training that the events that unfolded, induction, being left alone etc. caused her to be in such poor condition and it could have been prevented. My training has changed my views yes, I personally, remember I said personally, would never consent to induction again, I wouldn’t consent to an instrumental delivery or a caesarean just because my labour is taking too long, I wouldn’t consent to an elective caesarean. That’s because I know MY risk factors however, if there were other complications or it was a case of risk my babies life or have an instrumental or surgical delivery my views would change.

I honestly believe the answer is better antenatal education. Remember I said the trust I work at had 90% of women happy with their care, some of them had forceps, some had caesareans, some had complications, many will have had some form of injury. But they were happy because I believe our antenatal education is effective. Some of the stories I’m hearing on here are not comparable and this needs to be standardised across the UK so all women are getting the same.

Secondly postnatal care needs a huge overhaul. As I stated earlier we risk assess all women for urinary incontinece and refer to physio if they are high risk, I find it shocking that not all trusts are doing something similar. We will never fully prevent women having birth injuries but if we have prepared women for the possibility, detect it quickly and refer on to manage and treat it quickly we can stop birth injuries having such an impact on women’s life’s.

I think high forceps should be covered separately. 5% is one in twenty - that’s a fair number and the consequences are worse than low forceps.

Unfortunately yes I know three women who have had them with zero anaesthesia- not even a pudendal block. Barbaric indeed.

It sounds like you work for one of the better trusts :)

I had forceps delivery with DS 1 and a very speedy natural birth with DD. No time for pain relief with either. Maybe I'm mad but I still genuinely would look forwards to having another baby and delivering them "naturally".

I think warning women more about possible complications is fine, but it needs to be carefully measured so as not to cause 1000s of women severe added anxiety during pregnancy. Every pregnancy and birth is completely different, so just to apply blanket lists of a whole array of worrying issues- with serious likelihood would I feel cause added extra pressure and anxiety . Birth cant be (unless planned C sec- and are we really suggesting the whole country just resorts to this?) something you can physically or emotionally really plan or prepare for, as you have no idea what will happen on the day. For me, Watching loads of 1 Born Every Minute helped as presents so many varying scenarios, I was able not to panic when things did go wrong/took unexpected turns.

1 thing that I did find appalling was the aftercare, and my mother/older generation family also were shocked - the utter lack of any vaginal inspections by midwives visitors following my birth. No-one asked to examine me to check I was healing ok after the forceps/delivery. Turns out there were large clumps of tissue/scarring just left over, that only through having a smear test was detected, and then the tissue removed. Apparently this used to be 1 of the first things midwives did at home visits, but I really felt they avoided "going down" there??

Well our trust was recently voted the best in the region for maternity care, very proud of it and the people I work alongside.

Don’t forget that high forceps come in 2 types also. You can have bog standard high forceps (that are actually referred to as mid-cavity forceps) or rotational high forceps (that turn the baby before delivering). Then you’ve 2 types of low forceps depending on how low baby is. The increased risks come with rotational forceps, Kielland forceps, they are the ones banned in some countries and they are the ones that are very rarely used in this country. There would have to be other risk factors meaning a Caesarean section would be too risky before a doctor decides to use them usually.

This is an intesting article which explains that many of the increased risks of rotational forceps come from the fact that doctors rarely use them and also are inexperienced and unconfident with them. That’s why many doctors will opt for caesarean instead if they are needed as they are better trained in performing them. There would have to be a real indication for a doctor to use unfamiliar instruments and that’s usually because the baby will die if not delivered immediately. I suspect that the vast majority of women, even those given all the information beforehand, would consent in that situation.

Forgot to post the link sorry

obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/1471-0528.12603

I also know someone who had a forceps delivery without adequate pain relief (think they’d tried an epidural earlier in labour and it hadn’t worked). She was and still is very traumatised by it and will carry the physical and mental effects from it for the rest of her life. She did complain, nothing happened. The hospital also managed to lose her notes when she asked for a debrief and explanation of why it had all gone so wrong Her care (or lack there of) still makes me unspeakably angry.

I think care during delivery varies drastically depending on where you are in the country. In my area, it’s actually pretty good and women I know who have had complicated births have been happy with their care.

This is at the cost of postnatal care, however, which is completely non -existent. It would be great if we could have both!

Catching babies

You say talk about the common ones, high forceps are only used in 5% of births, is that classed as common?

I would say 1 in 20 is extremely common. As a comparison, when the dr was doing the consent form with me for my cs, she discussed bladder/ureter injury when the risk of that is only 1 in 1000. In fact from what I can tell, most of the risks of cs mentioned - excess bleeding, bowel/bladder injury, cut on baby, blood clot, death - are less than 1 in 20 (far less). But they are discussed in great detail in advance, even if you aren't even having an elcs.

That doesn't really make sense.

Btw not having a go at you Catching babies, you sound like a very knowledgeable and caring midwife and you have shared a lot of interesting information on this thread.

I understand it’s common when you look at it at 1 in 20. I guess I don’t see it as ‘common’ as in 5 years I’ve seen 1 high forceps delivery, many low forceps of course. Some areas have much higher rates, some lower.

The induction rate at my trust is 26% that I see as common and yet the possibility of needing induction (although I’d argue that many are not needed) isn’t discussed until around 39/40 weeks of pregnancy. 90% of first time mothers will have some form of perineal trauma and yet research such as perineal massage to reduce this isn’t covered as standard in antenatal education. Postnatal depression affects 33% of mothers yet how many of you had that discussed in pregnancy? Or had more than the casual “are you feeling well emotionally” postnatally?

I guess what I’m trying to say is that many many areas of care are lacking, many things not talked about enough and many improvements to be made. For me it makes more sense to be using the very limited time and even more limited resources to be focussing on the issues that are likely to affect a large proportion of mothers rather than ones that are likely to affect a much smaller percentage. Not that it makes it right to be making decisisons such as this and deciding what is “important” enough as it’s all important but we all know it can’t all be done. The NHS is in crisis, as much as we would love it all to be given equal importance and equal time and attention the reality is it won’t happen.

And thank you @thursdaydreaming that’s lovely to say. It horrifies me hearing some of these stories and I can honestly say these kind of incidents are not normal and most of my colleagues would be equally horrified. Don’t get me wrong I have met midwives that have horrified me also and I’ve wondered why on earth they continue to practice when they have such disdain for the women in their care but they are the minority. I imagine all professions have such people.