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. 

My son would have died without forceps - there was no time for a c section, DH meekly asked ‘we’d rather not donfordeps, can she have a c section instead?’ - sounds ridiculous now we know what the full situation was! My son (first baby) was born in 40 mins and so there was no time to get into theatre etc.

Hope you don’t get to that point anyway and have a lovely straightforward birth!

My sil is an obstetrician. She is confident she can get a baby out faster and with fewer complications with forceps than cs in an emergency. You need to bear in mind that if baby is low down and stuck, oxygen flow is compromised so there often simply isn’t time for a cs. We’re talking literally minutes to deliver the baby before there is a risk of brain damage. In those circumstances forceps is quicker than CS. If you are 100% that you would refuse instruments, then you need to request an ELCS.

@Singlebutmarried my DD would not be here either.
I wasn't asked if I wanted to have forceps and wouldn't have expected to have been given the circumstances. It was clear that the baby was in danger and the doctors did what was necessary to get her out safely.

If you are absolutely adamant that you don't want an instrumental delivery, as pp I would suggest an elective c-sec.
If they need to get your baby out quickly and there isn't time/ availability in theatre etc to give you a c-sec you could be putting your baby's life and potentially yours in danger.

There may not be many cases where it's not too late for a CS in theory, but many where it wouldn't be desirable compared to an instrumental delivery

As pp have said, pulling the baby back up the birth canal to a position where it can be delivered isn't straight forward

I've only had ELCS and had the most straightforward recovery in the world, but looking at my friends and nct group who had forceps vs EMCS, the recoveries were fairly similar, and not really comparable to a ELCS recovery

Btw the 'no driving for 6 weeks' thing is a total myth. Everyone I know who has had a CS was driving within a few weeks, and my insurance company had a section on their FAQs about notifying them, which basically said 'you don't need to notify us'

Oh and op, no one actually looks at your birth plan. I think it's just there to get you thinking about the birth and make you feel like you're in control (haha!)

Oh and yes he did have forceps bruises and later developed a torticollis, so he could only turn his head one way for a few weeks. Cranial osteopathy sorter that. I had a lot of physio afterwards but all back to normal now. Would rather all of that and a live baby than the alternative! :)

The problem is OP “trickier” means riskier. For the baby, for you.

It doesn’t just mean the doctor has to work a bit longer to do it or try a bit harder. It means potentially there could be a poor outcome.

I do think at this point you have to trust the person with the medical degree and experience to make a judgment call on what’s right in that specific situation. By all means put you’d prefer a section over an instrumental and remind them of that if the situation arises. But if they say they think an instrumental would be better then I would go for that.

DS1 got stuck so they used a ventouse. I’ve suffered no ill effects from that and neither has he. He needed a bit of help to get him breathing once he was out so I’m glad he was born as quickly as he was.

Have a read into the differences between high rotational forceps (imo a c-section is definitely preferable, they aren't even used anymore in certain countries) and low forceps and ventous which could be safer for the baby as they would be low down by that point.

My baby was stuck, i did not consent. Had EMCS and happy that was the best decision for us
OB was very pushy trying to bully me into a high foreceps. Thank god i stood ground as that is the most likely to cause significant injury.
Im in the uk too..very upset with the forceful nature, truly believe the doctor was trying to keep his csection percentages down

OP if you absolutely do not want instrumental delivery (I don’t either), have you considered an elective cesarean?

And even a full on crash section takes 12-15 mins from decision to baby out. That’s if you’ve got a working epidural on board which can be topped up instantly. That would be a long time if baby’s heartbeat is plodding along at 80bpm.

My son also wouldn't be here had it not been for the forceps. My labour was awful as I ended up in theatre anyway due to a retained placenta and had a general but I'd do it all again. He became distressed as I was pushing and too far down for a section so needed the forceps.

@Scotinoz I DO trust the HCPs which you'd see if you'd read my post properly...

Our (excellent) NHS session midwife emphasised the importance of informed consent during the labour process and understanding what's being suggested and why - she was brilliant. I did speak to her afterwards (and will speak more to my community midwife) but I am asking questions about this specific situation to be sure I understand as well as possible.

I’d have my forceps birth (failed ventouse) with my 10lb baby a hundred time’s over before I’d have another CS. Both births were as fine as a forceps and and EMCS could be but the recovery was MUCH easier with the forceps birth.

I think by the time they decide to go for the forceps it will be too late for a emcs. Even if they theoretically could then go for a c section, it’s v unlikely to happen. They will want the baby out ASAP and organising then putting you through for surgery will delay things possibly risking the health of your baby.
I had a elective c section. Was easy. Was driving after 3 weeks.

pandarific - no problem. It’s just really hard to predict how your delivery will go. I’d say it’s ok to express preferences, but absolutes aren’t sensible.

My baby (now 5 months) was one of the unlucky ones that ended up with a facial palsy due to his forceps delivery. He was on neonatal and tube fed for the first couple of days. A report was written about his birth because his admission to neonatal was an unplanned one.

BUT even though this ended up happening (and happens in less than 2% of forceps deliveries) it was still safer than a c-section at this stage with him needing to be pulled back up the birth canal. He healed completely and you'd never know. If I was in the same position again I'd make the same decision as the risk at that point was lower than a c-section (and would have been even with what happened) Good luck with the birth, you will be in great hands.

Had ventouse with my first. DC was stuck, and showing signs of distress. It was an emergency situation so there was no time for a section, nor would I have wanted one given how far down the birth canal they were.

The procedure was very quick, I was relieved and grateful that my baby was out alive. Neither of us suffered any ill effects.

Keep an open mind.

OP have you thought about why you don’t want an instrumental?

For me, it’s the risk of vaginal injury, and the total loss of control, plus the need for stitches. So a cesarean is obviously the solution.

If your reasoning is something else, perhaps looking at that might help you come up with a solution, whether that’s a cesarean or not?

Oh and I was afraid they’d decapitate my baby which was totally irrational but absolutely terrified me.

Sometimes an emcs isn't an option because the baby is already too far down.

Whilst I was in the pushing stage with my first, they had a ward round and the consultant said to the midwife, they would be back within 10mins and it would be instrumental as I had been pushing too long. The midwife shooed them out and said to me, lets do this, I don't think you need help. Baby was fine, I had enough energy and I was shocked they had said this (but was pretty away with it at this point). The rest of their ward round took too long and by the time they came back, baby was out. I did question this approach because everything was fine so why would that need to be an instrumental birth? I just needed more time and luckily got it as they were delayed. Not saying every birth is like this, I was delivered by forceps. But I do think make your preferences known as it might guard against an overly risk adverse approach.

Also bearing in mind that having a section doesn't obliterate the need for forceps on the baby. Wrigley's forceps are often used to help deliver the baby's head at LSCS if the head is high and the baby needs lifting out. More common with elective sections vs emergencies, but I have had babies born with the forcep marks at LSCS.

My little girl was born in theatre following episeotony and high forceps. Her bruise on her cheek faded in 24hrs. I healed really well. I was keen to avoid c section due to being stuck without car and partner working away. I could not fault the delivery she was is distress and I had a fever. Delivering her safely was my only goal.
I am a HCP and I encourage my patients to be open minded as we can rarely predict any labour how it will go.