Following on from the OBEM forceps thread...

[ZombiePlan]

This isn't a thread about a thread, so much as a question that occurred to me when reading that thread.

One of the midwives posting on that thread said something along the lines of there being different "levels" of forceps delivery - the high ones, then ones where women just need a bit of help "for that final part where we can all see it but she just can't get it round that bend and out" (hope direct quoting is not bad form, but she put it more clearly than I could). Can anyone tell me where the boundary is? In terms of stations? The forceps vs cs question seems to come up fairly frequently on here and most people seem to think that cs is better than high forceps but that a "lift out" is better than a cs. I just wondered where the boundary was IYSWIM.

The reason that I'm asking is that I had a ventouse delivery. I said I didn't want an assisted delivery unless it was low cavity and non-rotational (I felt that minimised the risks - all the really bad stories seem to be from high forceps or rotational deliveries - I was comfortable with the idea of a straightforward lift out). The registrar told me it was low cavity - but when I looked at my notes afterwards, she had written that the baby was at +1. According to RCOG guidelines, this is actually mid-cavity. Had she told me it was +1, I would have refused consent. I am wondering whether she felt that cs would be a dangerous option at that degree of descent and told me it was low cavity to get me to consent, because she felt it would be a better outcome. I would really appreciate it if anyone with a medical background could give me their views on this (I mean views on at what point a cs is better than forceps and when it would be the other way around, not views on the registrar not telling the truth - I already know what I think about that!).

Thanks

Bump...

Really difficult but didn't want your post to go unanswered. Just my opinion/observation now (I am a midwifery sister with 16 yrs experience). I think although we describe these things anatomically, measurement is subjective, as all things in obstetrics. It is all down to the practitioner.

Generally plus 2 is where the head is easily visible and an instrumental in this case is a 'lift out'

From my experience the cut off between instrumental and cs is when the baby is -1 above; they just wont attempt it.

Station 0 and plus 1 is where it gets grey. Anatomically the ischial spines which is the bit of the pelvis that we judge the plus or minus against, IS mid cavity. But if the baby is just below (not quite plus one) they may attempt an instrumental. The position and size of the baby is almost as important too and I think this is a big factor in deciding mode of delivery and the success of an instrumental.

As we read on these forums, the outcomes of forceps deliveries vary considerably which means there are many factors determining the well being of baby at birth. Because of this it is impossible to impose general limits for delivery methods. The shape of the pelvis can be a factor too - I have seen babies where the top of there head is visible but it just wont deliver vaginally because of pelvic shape.

I am sorry if I haven't been that specific but I have tried to explain why it isn't clear cut. If only it was a precise science!

Thanks, laluna - that's really helpful. It seems as though my DS was in the grey area that you describe. Can I ask a further question - how much weight would be given to maternal preference in these circumstances? The reason I'm asking is that I made it totally clear that I had a strong pref for a CS (both because of the risks associated with instrumental deliveries but mainly because I've been the victim of several sexual assaults - people fiddling around down below makes me extremely uncomfortable). If +1 is the "high end" cut off for instrumental aboce which they won't even try, what is the "low end" cut off for CS - i.e. was +1 too low to make a cs possible regardless of my wishes?

Sorry for delay in replying.

Re maternal preference, it would depend on the obst. but they would all have a fairly strong attempt to talk you out of a cs. It would depend how forceful you are and whether a plan had been devised antenatally. The reg would probably involve the consultant in these circumstances.

No, plus 1 station isn't too low generally for a cs but there may be difficulty in getting baby out depending on size and position. That can be a horrible position to be in and the babes can be a bit traumatized. HTH x

Thanks - I really appreciate you coming back to respond to me. It was really helpful

Like laluna I am an experienced midwife and I would say that a lot of 'easy' lift out deliveries are at +1 station, it is very subjective though of course.

Any instrumental delivery is going to involve 'people fiddling around down below'. If a babys head is + 1 below the spines to do a section would, in most cases be quite difficult and traumatic to the mum and baby and would involve someone inserting a hand to push baby back up. Also the risk of haemorrhaging is far higher during a second stage of labour section than it is during other sections.

Hope this isn't too much information but unfortunately when that stage of labour is reached, an assisted or operative delivery is going to involve quite a lot of 'fiddling down below'.