Not consenting to instrumental delivery?

[pandarific]

I'm pregnant with my first, and mulling over what to put in my birth plan about consenting to forceps or ventouse.

I'm not anxious about labour as such, I'm low risk and giving birth in a hospital with one of the best consultant led maternity units in the south east, and my community midwife and the NHS class has been excellent so far versus some of the things I've read on here, they've really been brilliant! but there is one thing I'd like some more info on, if any HCPs here can help?

My first priority is delivering my baby safely with no injury to them, however I am concerned about consenting to forceps and ventouse, having read some of the stats around birth injury - and it's not an insignificant risk, if I've read correctly that the likelihood of having an instrumental delivery with a first baby is 8-12%? I'd much rather a c-section than a 3rd or 4th degree tear, prolapse, or ongoing issues with incontinence - I know CS is major abdominal surgery but the inability to drive after is not an issue and the other risks seem quite low to me. I really think I'm okay with that possibility.

WIBU to put in my birth plan that I don't consent to instrumental delivery? My understanding is that then, if I was unlucky and the baby did get stuck and the baby was in distress, the next move would be to EMCS? I know I could leave it out of my birth plan and simply decide in the moment, but I am worried that a) I might be too out of it to be able to process info that I'm given and make an informed decision b) might the discussions and deciding cause a delay in getting the baby out safely versus a quicker decision to EMCS if I just had 'do not consent to instrumental delivery' in my birth plan/made them aware of it up front?

I'm sure I'm missing lots of detail and not considering the full picture, so if anyone has any advice / stats etc they could link me to I'd be really grateful. 

I had on my 'birth preferences' (didn't want to call it a birth plan as there'll always be something that isn't what you ideally want!) that ventouse or forceps were to be used as a last resort.

I think I wrote that unless medically necessary I will try different positions to help baby out etc and to give more time before resorting to them.

Maybe not wise to say you don't consent as in the moment if that's what it takes you will do anything to get baby out. I didn't want an episiotomy but as soon as baby was struggling to get out and they told me it meant he'd be born within the next 2 minutes I said YES straight away.

My girl wouldn’t be here without forceps.

She’s fine. Had a small mark on her cheek for a couple of days.

The need for an instrumental arises once you are close to delivering and the head is already tightly in the birth canal. At this stage a c-section is also tricky as baby has to be pulled back up. Often safer at that point to pull down with forceps or ventouse.

No one would offer them without good reason - only because they reduce the risk if baby is distressed (risk of oxygen deprivation) or stuck. (Risks to your undercarriage slightly separate matter though).

If you are dead against need to think about elective section from the beginning- otherwise have to go with the flow and trust the advice you are given.

Thanks @BearCubX - did you need the forceps/ventouse in the end, or did the episiotomy do it? How was your recovery?

You need to discuss this with your healthcare providers.

Caesarean sections at full dilatation carry risks in terms of post-partum haemorrhage, it can be very difficult to get the baby out if the head is deeply impacted in the pelvis. If the baby's head is high up or cannot turn, then yes, LSCS is the only way that baby is going to deliver, but technically it can be a more difficult operation compared with someone who has not dilated.

If you have a baby's head that is so close to delivering and requires a 'lift-out' there's no way I'd entertain the notion of a section - pushing the baby's head all the way up the pelvis risks rupturing the uterus and injuring the baby.

DD and I would have been in real trouble without ventouse. She’s 2w and awesome. At the point they realised they needed to use instruments it was far too late for a section. There were no real signs there would be problems earlier. On this basis, YWBU.

22 not 2w

Depends for reason for instrumental, so say if baby was not far from being born and there was a significant drop in heart rate it would probably be significantly quicker to get baby out via ventouse than to go for a crash section. If it was for something like maternal exhaustion or pushing for prolonged period of time I'd ask them position of baby, how high the head is and what instrument they would be using. I'm a midwife and often people express not wanting instrumental deliveries, yes some can be awful and those in hindsight I'd say should have probably had a section, however some are just a lift out. If you've done all the hard work of labour and just need a bit of a hand at the end it would be such a shame to have a section as this can have an impact on future fertility and pregnancies.

This is a very tricky one as in the moment things may feel very different, and a c-section is not an insignificant thing to endure.

Forceps and ventouse do have their own risks however I believe they are avoided unless essential. Can you talk to your midwife about instrumental aid in more depth vs emcs?

I'd be wary of having something so clear on your notes as it could be all the risks then of an emcs straight away when in reality a tiny amount of ventouse aid and no other issues and baby is here safely.

I’ve had 2 c sections and the babies were both stuck anyway! I’m short and my babies are quite big. They needed forceps to deliver my daughter even with the c section! She was fine though, just a small bruise. Yes if I were you I would definitely make your preferences clear upfront and discuss it all ahead of time.

@cardibach as I understand it, there's not such a thing as 'too late for a section' unless the head had been delivered? Though as a pp said it's trickier?

My ds wouldn't be here without ventose.. I wasn't asked permission. It was a pretty instant case of baby showing distress ventose and baby out - from active stage of labour my son was born in 31 mins. I did need some stitches but I wasn't particular sore after was walking about fine etc (may well have been adrenaline mind you as my son was in nicu for a week, he's fine now)
I'll be honest I didn't make a birth plan as I figured it would stress me out if things didn't go exactly as I had planned

@pandarific thankfully not, a small cut and me and him both relaxed and he came out straight away! He was slightly premature so doctors were hovering behind the midwives about to step in and firmly encourage the ventouse/forceps but I genuinely think hypnobirthing was what helped me stay calm enough to relax and get him out. So if you haven't tried it I'd definitely suggest it!

I can't complain about the recovery at all actually, or the whole experience. I was very lucky.

Wishing you all the best with it

my baby got distressed (turns out I am prone to v fast labour and had one constant contraction for 2 hours) his heart rate kept on dropping. The time it took to get him out was 10 minutes: for a EMCS would have been far more complicated someone else was in theatre being prepped for one (the surgeon came and got him out then did her EMCS then stitched me up) and I did not have an epidural so all of that time would have potentially been catastrophic

I would say last resort and you want to be asked to give consent.

The bottom line is that you can only consent or not consent at the time. It doesn't matter what it says on your birth plan. By all means, write it, but I would be inclined to write 'I am strongly against and fearful of having an instrumental delivery; I would like to avoid this by all reasonable means, including c-section.'

pandarific she was crowning. Had been for a while. No indications of issues before then. She was long, my pelvic bone is quite flat, she got her knees stuck. I wouldn’t fancy a section to pull back a crowning baby,would you?

Stitches were for episiotomy I meant to say

I also would have preferred a C-section to forceps because of fears of long term damage. However I ended up with forceps and 8 weeks postpartum the doctor says my episiotomy has healed really well and I only had one other small tear. I’m not back to normal yet but I dont think I’m in any worse a position than a lot of non-instrumental deliveries. So they don’t have to be as bad as some of the horror stories, and my fears didn’t materialise.

Anyway to answer your question, my understanding is that an EMCS isn’t a realistic alternative a lot of the time as by the time forceps are required baby is in the birth canal and would have to be pulled back up for a section. I’m not a doctor so will stand corrected!

And I was so out of it in the latter stages of labour I wasn’t unable to chat through options in the moment so it’s as well to get something written down, but more importantly to ensure your birth partner knows your preferences and can query options if an instrumental delivery is suggested.

I had it on my birth plan too . No one read it. I had forceps. Was what was required for a quick safe delivery. No post birth problems at all thankfully.

I refused consent for forceps during labour. They tried to push me on it once or twice and i just reiterated that "I do not consent to forceps, I do not want a forceps delivery". DS was never distressed (he was being monitored) he was just stuck, I had what's classed as a semi-elective C section. It was actually very swiftly put into action once the decision had been made, from signing papers to the section in under an hour. I never dilated due to his size, position and presentation so would have always had to have a section.

I didn't have a birth plan written down, and tbh, it had all gone to shit by that point anyway.

@cardibach no, probably not! I'm not being arsey by the way, I'm asking questions and checking my understanding.

I wouldn't let them near me with high rotational forceps again. In fact I'm seriously considering requesting a section for a second child.

Low risk doesn't equal no risk.

Personally, I think you'd be insane not to consent to instrumental delivery. Yes, sometimes it goes wrong. Yes, sometimes people fuck it up. Yes, I like to inform myself of the pro, cons, ins and outs of what ever I'm doing.

That said, when the Obs and Midwifery team decide that forceps are needed to safely delivery my child, I trust their knowledge over my Google research.

Oh and my recovery from the ventouse even with internal stiches was far far easier than the recovery from my elcs

For me as I said the section would not have been possible and the time taken to prep me far too long as I had no pain relief. And I just wanted the pain to stop

I honestly wouldn’t put too much thought in to a ‘birth plan’. No one ever asked or looked at mine. I had ds with forceps and episiotomy, as did a couple of friends. No complications and quick painless recovery. At the time, they told me they were giving me a spinal and prepping dh for theatre as they thought ds wouldn’t turn. I thought beforehand I’d be SO happy with a csec and painless delivery, however in the moment I wanted to get him out anyway i could safely and hopefully without a csec because I didn’t want to stay in or have the recovery! Be flexible. Open minded. And go with the flow at the time.