Childbirth injury risks

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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?

There is so much misinformation on this thread!

I absolutely agree that women should be able to make an informed choice about their method of birth after discussing all the risks and benefits unique to their situation but to state that caesarean is safer, easier, less likely to cause injury is absolutely wrong for the vast majority of women.

Some of the birth injuries listed here would have still occurred if a caesarean was performed and a caesarean carries much higher risks for both Mum and baby for the vast majority of women. It’s major surgery and should not be entered into lightly.

I’ve seen babies sadly pass away from respiratory distress, caused by an elective caesarean. I’ve seen babies have blade injuries during Caesarean section. I’ve seen woman haemorrhage uncontrollably due to the caesarean and end up with a hysterectomy to save their life. I’ve seen women end up with life long catheters due to injuries caused by caserean. I’ve seen women have to have repeat surgeries due to poor healing after caesarean. I’ve seen one woman become paralysed as a result of the spinal anaesthetic used for caesarean. I’ve come across, although not directly dealt with, a woman who died from complications of a general anaesthetic given for Caesarean section.

Of course Caesarean sections sometimes safe lives also, but if statistically you are likely to achieve a vaginal birth with minimal injury it would be unethical to expose you to those risks needlessly.

While risks of vaginal birth also exist, the rates are far far lower than those from caesarean in low risk women.

I agree with the lack of info from health care professionals which is why I googled(not this site as I needed cold facts).Prenatally I had one class on car seats and the rest were cancelled.Because of the way rural health is organised my communityidwife was not linked to the hospital I was booked into and there was no communication between the two(so for the first 18 weeks of my pregnancy I had no midwife as mine was ill and not replaced.I was bleeding so had scans and a nice radiologist chatted about downs etc and I found I could self refer for CVS.
Finally had a communityidwife after refusing to leave the GP surgery until someone at least could give me a phone number.
I spent the last couple of months working in a clinic with men having vasectomies.I was a visual reminded of why they were there and they took their minds off it by regaling me with their wives terrible experiences!
But on after care there is silence no matter what kind of birth you have and almost nothing in the way of home visits either.
Not just what to expect but how long it realistically goes on for,when you should seek help and who from.

This legal case was a landmark for medical consent and was in relation to birth injuries suffered by a baby. The nob of the ruling is consent being the choice of the patient and what the ordinary, sensible patient would choose to do if given the correct information. Prior to this the question was what a body of doctors would choose to do in a given situation.

So legally we should be giving high quality evidence based information to women and allowing them a choice. After a very long career in the field I’m not at all certain this does happen very often. Clear cut cases are easy but very few situations are clear cut.

@catchingbabies and that is why it so important for the correct information to be given out and evaluated. This is why there needs to be full risk assessment case by case.
My cousin had an emergency section after a 56 hour labour. She laboured at home with a birth pool determined to have her classic birth plan perfect labour. Unfortunately when she was told to push she was not fully dilated and ripped her womb pushing. She was blue lighted to hospital and they were both saved by emergency surgery.
Follow up to pregnancy number 2, and she had to decide what to do. She chose elective section. This was very complicated as when they got in there her scar tissue was so bad they had to cut through her bladder. After the op she was advised not to risk pregnancy again.
So I agree that in one sense there's misinformation on the thread but equally people can only hobby experience of those around them and advice, and often the advice is incomplete and poor. The truth is birth can be risky and as each one is different you can never be certain of the outcome each time or method of delivery.
I've posted up thread about my issue and have left out lots of information as it would easily identify me to anyone reading who knew me. I've put forward a basic case but actually it is more complicated.

Nub, not nob,,blush

You're welcome @coffee3 . If you haven't already seen it, this Which? tool is very helpful: www.which.co.uk/birth-choice/units

@CatchingBabies but were all of those things with elective sections? Or were a lot with emergency sections? And of course one of the reasons some women opt for a planned c-section is because it virtually eliminates the risk of them undergoing an emergency c-section which is riskier. When speaking of the risks of PLANNED c-sections it makes no sense to bring up risk factors of emergency c-sections.

Secondly a HCP could write a list of all the poor outcomes of babies left dead or brain damaged by vaginal birth, mothers permanently injured and maimed by instrumental deliveries, left with permanent bowel incontinence etc

I get that most of the time a straightforwardness physiological birth is preferable to a c-section but some women, depending on their own risk factors, have quite a small chance of actually achieving that and it's understandable they would want to choose a planned CS over a high chance of forceps or an EMCS

The problem I found, like many others, is that it's nigh on impossible to get any sort of personalised risk assessment. I had horrendous SPD in my first pregnancy, and at 36 week midwife appointment I was finally referred to a consultant as it was becoming very obvious that birth was going to be hugely difficult - to be blunt, I couldn't open my legs!

First consultant - denied SPD created any limitations, stated it was just a "condition of pain" and an epidural would mean I wouldn't feel it. I knew this was bollocks, as even going swimming/bathing and exceeding my pain free gap in the water left me in absolute agony afterwards. Wouldn't acknowledge that immobility would increase my chance of intervention and just quoted standard stats at me.

Eventually they sent me to the see the chief midwife (can't remember official title) who had me try various positions and realised I'd struggle to give birth to a fecking hamster. Back to consultant.

Second consultant eventually agreed Csection was an option, but spent ages telling me about all the risks of it - but no discussion AT ALL about the risks of vaginal birth, either at a population level or specific to me. It was just glossed over, like the only option which carried risks was the section.

I'm expecting number 2 at the moment and SPD has arrived again. Saw consultant on Friday who was happy to approve a second section but again gave me the full section risk list but the only risk listed for VBAC was scar rupture. In no way are we being given balanced information, and I really object to that.

It can also be very difficult to find decent stats on ELCS vs EMCS vs vaginal birth - they're all very different beasts and the way the statistics are sometimes collated makes it hard for women to make an informed choice.

The problem many women have is this attitude:

it would be unethical to expose you to those risks needlessly

We know about risk. We would like to be given an honest assessment of all the risks and then be trusted to choose which risks we wish to take. Not arbitrarily told that you'll probably be fine or don't you want to just try it or the injuries you've received may have left you dealing with incontinence for the last year but that's only to be expected .

We just want to make an informed choice about how we deliver. I'm glad the RCOG agrees. Now it needs to be rolled out.

@boredandtired That sounds like absolutely appalling care, poor woman!

@elainethepain A mixture really, the risks are higher with emergency caserean rather than elective. Well except for respiratory distress syndrome, a baby that hasn’t been through labour is at higher risk of that.

I really think we need better antenatal education, so many women are totally unprepared for childbirth and could do many evidence based things to reduce their risks if injuries, perineal massage for example reduces the risk of severe tears but is almost never discussed. The problem as always is funding and staffing. Plus antenatal classes often have a poor uptake, the women who tend to need it the most are the least likely to attend and very few women attended with second or more pregnancies when it could be helpful to update on changed guidelines or new research.

@catchingbabies - around here, NHS antenatal classes aren't offered at all for 2nd pregnancies. I have an 8.5 year age gap and first (see above) was an ELCS, but even if I'd gone for VBAC with number 2 I'd still have been offered nothing. I'd have been meant to rely on 9 year old, unused information.

@Duggeehugs I started my post stating women have the absolute right to informed choice but I notice you ignore that. It is unethical to expose women to such risks, they can choose that yes but if a poor outcome occurs from that choice it will be the obstetrician being asked by a tribunal why it was agreed when it wasn’t it her best interests. It’s also having the time and sometimes the recent knowledge to discuss those risks in pregnancy when there is time to ask questions and have time to think. Women’s risk may change during labour but unless a medical need for caesarean presents it’s not the time to be discussing the pros and cons of continuing labouring vs converting to caesarean as a choice rather than as a need because we know women are going to find it harder to process and understand information when exhausted and in pain.

perineal massage for example reduces the risk of severe tears

Is there actual evidence for this? I’ve looked and can’t find any. Perineal support during crowning and proper coaching on when to push/not push appears to be the main factor.

@statisticallychallenged That’s such a shame. It really frustrates me that we expect people to get their own information when we know that it’s likely to be incorrect or misinterpreted. No other area of medicine would have such little preparation and so little information given. Added to the fact that antenatal appointments are 10 minutes long and usually always run over there is limited time to discuss these areas in those also, it’s just not good enough at all and there needs to be standardised care so that all women receive the same level or provision.

What womenneed to know is the risk of induction. That’s when lots end up with forceps and vaginal damage.

@bowlofbabelfish

Here you go, Cochrane review on antenatal perineal massage

www.cochrane.org/CD005123/PREG_antenatal-perineal-massage-for-reducing-perineal-trauma

@Catchingbabies I think when women talk about CS being a preferable option they are referring to a planned CS... some women, due to their individual risk factors, may find out they have over a 1 in 3 chance of an EMCS and therefore want to request an ELCS with this in mind. For a consultant to then try and put them off an ELCS with statistics also based on emergency c-sections is absolutely bonkers and makes no sense Yet for some reason is not abnormal.

I think it's also important to remember that women are individuals. Different risks are acceptable to different women. In the legal case mentioned a few posts back the consultant mentioned that she didn't tell women with that condition the risks associated with VB because 'Eveyone would just request a c-section'... I disagree with that, some women would whilst others would prefer to avoid major surgery at all costs. We are individual adults with individual minds and preferences!

Also the refusal to accept that a lot of women are intelligent enough to be told the risks and make up their own minds. Their bodies, their babies, their birth, their life.

When speaking of the risks of PLANNED c-sections it makes no sense to bring up risk factors of emergency c-sections.

Yes exactly. They are two different categories entirely.
Respiratory distress decreases with time of gestation - so a section at 39 weeks has a very low risk compared to one at 36.

From what I and dh have seen from a week or two poking through the literature is that studies are often poorly done, categories are not matched correctly, so apples are compared with oranges. Dh has spent much of the last week making the noise he makes when presented with shoddy data ;)

I’m pretty sure I will be refused a c. I’ve had one refusal and I’m perusing it further - it’ll be interesting to see what happens, because for all the talk of ‘a conversation to discuss why you want this and go over risk’ I’ve found that why I want it is irrelevant and the risks presented were biased and in a few cases incorrect.

Also to say that I work as a project manager/scientist in clinical trials. One of the responsibilities I have is drawing up informed consent documents for trials.

If I’d produced a document akin to the one sided spiel I was given, I’d be in serious, serious trouble, because we are expected to give ALL risks and benefits and to omit on such a fashion would have the authorities down on us like a ton of bricks and possible criminal proceedings (as is totally fair.)

Everything I've ever read says that CS's are more risky for mum and baby and cost the NHS a lot more.

IMO a CS should only be offered when there is a medical reason why a VB cannot be attempted or would be more risky than is standard.

I don't think women should get a full breakdown of the risks of each and free choice at all. If you have complete private healthcare and choose to pay for a CS, that's your choice.

But if it's the NHS paying for the birth (and the NHS paying to fix anything that goes wrong) then I think it's fair enough that they only freely offer the option that is both statistically safer and cheaper.

Agreed Elaine, risks should be presented as an individualised risk. So if you’re unlikely to achieve vaginal birth without an instrumental delivery or other trauma the risks of such a delivery should be compared to the risks of elective caesarean. Likewise if you have a high chance of uncomplicated vaginal delivery that should be discussed also. Some women will always be higher risk of complications no matter what delivery method and it should be discussed how to reduce their particular risks. The problem is the research we base these discussions on isnt individualalised enough to always do so accurately. I do believe women should be told if they are unlikely to achieve vaginal birth however and allowed to consider the risks of emergency vs elective caesarean.

I'm also sure I've read that doctors are way more likely to choose a non-medical planned CS for their own births which is interesting

@catchingbabies my apologies for missing that you'd made that point - I wasn't trying to ignore it, just posting in frustration.

I think the line I chose just resonated because of the sheer number of doctors and midwives I've seen through one very long failed induction (I finally said enough at 106 hours in - until I said 'no' not one member of staff had told me I could do so) and a second pregnancy, who just didn't appear to try looking at things from the sharp end.

As it is I've now delivered via EMCS and ELCS. Doubtless this colours my view.

There is risk and unknown every time, I just hate that it's played down so badly.

And remember a lot of the research is now outdated but it’s unethical to repeat them as ethics guidelines have changed hugely so sometimes we are using outdated poor evidence. Induction of labour when overdue for example. That was a horrendous piece of research and the results are so inaccurate but we can’t repeat it now so we have to follow the guideline to offer induction even though we know that actually it’s most likely wrong.

Obstetricians are more likely to chose elective caesarean yes, they never see normal birth and only get involved in emergencies when it all goes wrong so their perception is skewed by that. Likewise midwives are more likely to choose vaginal birth as they see the vaginal births that have no complications. It’s all about your own experiences.