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. 

Reading these there seems to be a difference between those instances when the baby was in distress - often caused by fast labours and not having pain relief - something you just can plan for. Here instrumental deliveries are necessary as the time taken for an EMCS is too long. This though is often the scenario where you are too out of it

The second where the baby is stuck and needs rotating using forceps I think you definitely can refuse and insist on a c section instead and talk it through

I was also adamant I wasn’t having an instrumental delivery so I had an ELCS. If that’s what you want then you should request one too.

Having had a pretty bad 3rd degree tear (not from an instrumental delivery, baby had hand by her head), I would still rather have a tear than a C-section. The sown up tear wasn't that painful during recovery (to the extent that I didn't bother with the painkillers because remembering when to take them, while dealing with a new baby wasn't worth it) and has healed up fine. No problems with anything even sneezing with a full bladder!

I had on my birth plan that I do not consent to forceps and would rather have a c section if baby was in danger. first baby was emergency ventouse and second was a natural delivery. I dont know if they read my birth plan for DD1 or if ventouse was standard practise as there were complications, but I got my wish of no forceps. my community midwife was extremely understanding about my concerns and said she wouldnt have them either. I told the midwives on labour ward when I got in so everyone knew my wishes. its your body you can ask for whatever you need, but be mindful that in an emergency plans can and do change.

I had forceps delivery last year. I was absolutely petrified going into theatre, I begged for a EMCS but in the end went for the forceps because I was completely out of energy and both me and baby were in trouble at this point. It was absolutely fine for me, had an epidural and didn’t feel a thing. DS had two red lines on his face from the forceps that disappeared after a few days. I had stitches for an episostemy tear that healed really well within a couple of months. I think in the moment you just do whatever you need to in order to get the baby out safe and birth plans go out the window. I hope you don’t need to go that route anyway though!

I wouldn't be here without forceps. Even that took a broken shoulder and an indent mark on my head that is there to this day.

I'm certain my DM would rather I was here...

C sections aren't without risk either though, each method of delivery has risks and these will be considered by the staff before making a decision. I absolutely did not want an assisted delivery if I could help it, so I put in my notes that it was only if absolutely necessary. But generally speaking they won't do it unless they deem it necessary anyway.

We’d both be dead without the high rotational forceps. Both with long term damage and I will never have another child but we are both here so I am forever grateful that the doctors did what they could for us. You never know what will happen on the day, no point in overthinking it. Just do what the doctors suggest if it comes to it.

My birth plan said "no instrumental delivery - if things are heading that way I'd rather have a CS". In the end she was distressed, time was of the essence and I ended up with forceps. But I think it's a perfectly reasonable thing to to do and they did at the time asked me which I wanted, with the strong recommendation that she needed to get out asap and forceps was quicker - but if I refused they'd do a CS.

If you go for a vaginal delivery, have a read into the link between epidural and assisted delivery. An epidural increases the risk you will need forceps (or so I was told). So I decided to avoid an epidural if I could, and it may be you would want to as well to minimise forceps risk.

Irony was I ended up with forceps and no epidural, which just goes to show you cannot plan with any certainty. As PP have said, an elective section may be best if you’re unwilling to consider forceps regardless of the circumstances.

I would personally keep an open mind. Go in with the mind that you'd prefer not to have instrumental intervention, but that if that's what it will take in the moment to get baby out then that's what it takes.

There is definitely such a thing as too late for a c section. My first baby was stuck, cord round neck, stopped breathing. If we'd gone to theatre, he'd have died or at the very least suffered major brain damage by the time I was prepped for surgery. Sometimes it's not the quickest process, even in an emergency. Ventouse got him out in the end.

Second baby was an emergency c section after failed induction. It was honestly the scariest time of my life and I would hope to not repeat it, I'd take ventouse a thousand times over.

Everyone is different of course, there are no guarantees no matter how you give birth. I just personally wouldn't outright refuse anything. That thing you're refusing could be the thing that gets your baby out safely.

I wasn’t thrilled at having an instrumental but it really was the best and quickest way to get my baby out as she was distressed and stuck. I needed an episiotomy and ventouse. After a 3 day labour, I have no doubt that an emergency section where they had to push her back up would have been more traumatic and dangerous than the instrumental . The instrumental bit was quick. I recently had a debrief and have the timings:

2.31 dr examines due to slow progress. Prep for episiotomy.
2.37 head visible
2.40 concern re heart rate and fetal distress. Decision to do instrumental asap.

2.43 ventouse applied (and not forceps as originally planned because of head position)
2.44 first pull good advance
2.45 second pull
2.47 born and cried.

I refused forceps - I was fully dilated and had been in second stage labour for hours (not joking, it was hours!) and they wanted to try a forceps delivery in theatre. I refused and got a csection. At no point was the baby in distress but I didn’t want to deal with an episiotomy plus csection.

If you are 100% that you would refuse instruments, then you need to request an ELCS.

I agree with this^^. Though I had an ELCS with dc2 and nearly needed forceps as he was quite well wedged in there! I had ventouse and shoulder dystocia with dc1. It was a scary birth, but that was due to dc1 being born with very low APGAR score, not breathing etc. I had hardly any injuries at all. That whole area was back to normal pretty quickly, luckily for me. We did both end up with serious infections though, as it was a very long labour, which was also quite scary, but we are now completely fine. We took a bit of time to recover and feeding went to pieces etc, but I think it was all just very bad luck.

I preferred the ELCS personally, but recovery was about the same, aside from the infection with dc1.

All 3 of my deliveries have been straightforwards including my 1st, so it isn't always a case of things being difficult.

Having said that first, my nephew's gf has just had a baby, with the use of forceps. It was literally a case of forceps or crash cesarean (under GA) sometimes things really don't go as planned.

I had in mine that I wanted to do everything possible to avoid an epidural as I have a theoretical risk of complications, but I also had a clearly stated alternative. (It would have been a GA)

I was told that they could get a baby out via c section in 8 mins but it would involve a general.

I had a planned c section for medical reasons and loved it but trust me, OP, the baby won't read your birth plan and however you give birth if it comes to it you will do anything, anything at all to get that baby out safely.

My DD was born assisted by a ventouse, she was already well into the birth canal when she became a little stuck and her heart rate dropped. Quick episiotomy and she was out in minutes. She was absolutely fine not a single mark and I recovered quickly. As much as dealing with stitches etc after wasn't ideal, in my opinion a c section would've been much much longer to recover. Just my story! My advice would be not to put that as you could end up with a large op when the alternative (for me) really wasn't that bad. Hope it helps, ultimately up to you, good luck.

Don't make a plan.

My 2nd was forceps. She was stuck and in distress and it got her out before they'd even finished prepping the operating room.

Yes it hurt, no it wasn't pleasant, yet it hurt for a while afterwards but it worked, I was home the next day.

After a c-section isn't not just driving, it's picking up things, including your baby.

I had ventous with first child. No issues. Much quicker than a cesection too and probably better give that he was already pretty far down the birth canal. What had your midwife said about it?

Both my babies were instrumentally delivered. Ds was failed ventouse then forceps after delayed second stage - cord was 3 times round his neck. Episiotomy and entonox and there were maybe 15 people in the room (teaching hospital) but by that point I just wanted him to be safe. Birth plan could have been carved in stone but I didn't care how he came.

For dd I didn't even write on my birth plan. Get the baby safely out please.

She ended up being delivered by ventouse in theatre and her cord was cut before her body was delivered. Again I just wanted the safest outcome.

Please speak to your midwife team op and make sure you have someone strong enough to speak up for you when the time comes!

I had ELCS and I couldn't have done it any other way. You have to be realistic about what's possible and what's in your baby's best interest and how likely it is you'll get what you're asking for when labour is in full swing.

Many years ago I wrote a paper in university about forced cesarean sections - it must still happen. I'm sure women have forceps etc used without consent or coerced consent too.

When I read your post I thought you wouldn't accept delivery of a piano or other large instrument... I'm guessing that's just me.

I was the opposite to you I guess in that I desperately didn't want a c section. I didn't want forceps etc either mind you. Or an epidural! I just wanted a natural labour. My pregnancy was completely low risk all the way through until the last 2 weeks when he suddenly measured small and they recommended an induction when I reached full term. I ended up having an epidural and then had a long hard labour. He was back to back and got stuck and after about 2 hours of pushing they took me to theatre. I really really didn't want a c section so they gave me a massive episiotomy and used both forceps and ventouse to get him out. Sorry to be graphic, I'm not trying to scare you! Basically, I was about as out of it on various meds as is possible to imagine but I still knew what I wanted and was able to say it. I was still asked to consent at each point. I don't know if you have a birth partner but my dp was fully primed with my wishes and excellent at advocating for me through the process. I didn't make a birth plan because I decided at the end of the day that "safe delivery by any means necessary" was the only thing worth putting on it. My recovery was fine, the episiotomy was painful for a few days but I was given plenty of pain meds to manage it and it healed very well. I've not had any ongoing issues with continence from it or anything. My son was completely fine, a bruise on his cheek that faded fast and that was it. The biggest issue TBH was the epidural which caused me to spike a fever, and threw everyone into a panic over whether I had sepsis. Both DS and I had to spend a week in hospital receiving antibiotics while they waited for our test results. And between the drowsiness of the epidural and the fact he was taken away for antibiotics quite quickly, it took about a week for him to latch and start breastfeeding so I had to supplement with formula which I'd really not wanted to do. Anyway, that was my experience. I hope yours is different. Nothing went to plan despite having been low risk, but we both made it through fine and healthy which is all that matters. Of all the interventions we received, the instrumental delivery was (in my opinion) the least "harmful" bit.

i wouldn't rule out anything, you could get into trouble and have no time for a section... and if you are adamant no instruments, could mean, (assuming everything goes completely wrong and baby is in severe distress) they cant get you to surgery in time or they over ride your decision and just rip baby out and do far more damage to you than they would have in a controlled delivery .... so really think long and hard before dismissing anything that will get baby out in fast way if its required they dont use them if its not really needed

Ventouse failed several times with me.

To be honest I think my husband found it more traumatic than I did.

After a c-section isn't not just driving, it's picking up things, including your baby.

True. I loved my C section as I have said.
My baby was a tiddler at 5lb 12 so could carry her easily but I couldn't wear a sling and I really struggled to unclick the car seat from the isofix. Overall I would still do it again but my stomach muscles took a long time to recover.