Forceps vs ELCS

[bankholiday]

I had a horrible forceps (Neville Barnes) birth with DS (now 9 months). I had previously lost a baby, so my failure to progress might have been due to my poor mental state in labour, which unfortunately wasn?t acknowledged by anyone. Yesterday I went through my notes with one of the midwifes (who is also a counsellor) and she was great, but said although she would support me if I want an ELCS next time, the consultants would most likely refuse to do it.

I know it?s early days, and I have no plans of getting pregnant again for the moment, but I feel terrified at the thought of going through that again. I would only consider it if a forceps birth is better for the baby than an ELCS. Does anyone know, is this the case? I?ll see the midwife again in a couple of months, but I was wondering what your opinions/experiences are? I know the next birth can be straightforward, but there are no guarantees. At the moment I would choose a CS anytime, but I'm not sure the risks to the baby would actually be bigger than those of a (possible) forceps birth?

Under the new guidelines for ELCS, if one consultant refuses to do it they have to refer you to one who will (that's how I read it anyway)

I had a forceps delivery first time round. I am planning homebirth this time, if I go past 42 weeks I am refusing induction and if there's an issue, they can do a CS as I will refuse induction - the chances of intervention (including forceps and the damage I sustained during their use last time) are too high for me to risk it again.

I think ELCS is meant to be marginally safer for baby than a VB generally anyway, but less safe for the mother.

There are risks for babies associated with elective caesarians, mainly respiratory distress but this is increased the earlier the gestation of delivery.

For some reason I know a lot of women who have has CS, mostly emergencies. Based purely on my observations, the mothers who had CSs all report a great birth experience (including those who had EMCS). None of them had significant health problems after. There was one still birth in this CS group but the baby had died before the ELCS. Of my friends who had VBs several have had birth injuries ( one with a prolapse that cannot be repaired till she has finished having children). And most devastatingly one baby that died during labour. Yes recovery after a CS is longer than a straight forward VB. but as soon as a VB gets complicated or instrumental the difference is much less. I am now pg again. I will be stating that unless I can give birth with no induction and no instrumentation that I want a CS.

"and no instrumentation that I want a CS."

I don't see how anyone can promise that instruments won't be used.

OP - I believe a c-section might even be slightly safer for the baby, although a major operation for you obviously.

Having said that, I have seen friends recover far faster from c-sections than I did from my botched episiotomy. Having experienced how bad a forceps delivery can be for the mother it would be a c-section for me or no more babies.

There are people on here who have had NHS c-sections for no medical reason (though this seems to take serious detemination), so I think your midwife is wrong in saying you would be refused.

I'm one of those RB referred to - I asked for NHS ELCS for no medical reason and was given it. I didn't even have to press hard for it - just asked nicely. I believe the revised NICE guidelines that came out recently say that all women will be granted c-sections who ask for the - or something more relaxed about granting them anyway.

At Kings College London it seems that teh consutants have no problem in granting them anyway.

Good luck with whatever you choose.

Does induction increase risk of instrumenal delivery?

Sorry to contradict what people have said here, but there are way too many fallacies about the upcoming NICE guidelines thanks to appalling levels of journalism in reporting the draft. So bad the ROCG felt compelled to put out a statement on the reporting of the draft lambasting it as being completely misleading.

The final guidelines are due on 23rd November. There are a few days to go until they are confirmed. Fingers crossed they will stay the same, but they may yet change before the final version is published.

And here is the massive thing that the press seems to have mysteriously failed to report. The NICE GUIDELINES are exactly that GUIDELINES. They do NOT give women a RIGHT to anything at all.

They are suggested best practice guidelines for Trusts to decide to adopt or to ignore. Many WILL ignore them for their own reasons. They are under no obligation to follow them. It will put pressure on them to follow them, but thats it. It will be completely down to the policy of the Trust you are receiving your care in.

The new guidelines are not about giving c-sections for no medical need at all. They are about giving c-sections to women who my have a mental health need for one - because of fear. The emphasis, in the document is very clear about this. So where individual Trust decide to draw the line on this may well vary - to try and prevent "lifestyle" c-sections. Given the reporting and political pressure on this, I sincerely doubt that many Trusts will be keen to adopt the guidelines, in exact way NICE intend it.

The guidelines are not going to change whats currently happening a great deal anyway. They are simply creating a best practice on the subject for the first time, recognising that fear in childbirth has psychological consequences and should be taken seriously and try to create a full care pathway that includes counselling and additional support as part of a request for a CS (to help women go through with a VB rather than their request).

The suggestion that you will be able to walk into an appointment with your consultant and book an ELCS is utter nonsense. You could still find yourself with a battle on your hands and no guarentees at all. You could still go and see your consultant and wave the guidelines under their nose and they can still completely ignore you if the Trust policy is to ignore the guidelines.

Its worth remembering NICE guidance on IVF is as follows:
Offering 3 cycles of stimulated IVF to couples in which the woman is aged between 23-39 who have an identified cause of their fertility problems or unexplained fertility of at least 3 years.

And yet, policy from Trust to Trust ranges enormously, with some actually refusing to allow ANY IVF courses AT ALL, under ANY circumstances.

The data from the research that NICE looked at and that doctors are supposed to give to patients about risks is also different from what people have stated here. This is the 'official line'. The biggie to look at is, risk to the baby - they are more likely to be admitted to NICU:

Planned caesarean section may reduce the risk of the following in women:
perineal and abdominal pain during birth and 3 days postpartum injury to vagina early postpartum haemorrhage
obstetric shock.

Planned caesarean section may reduce the risk of the following in babies:
neonatal intensive care unit admission.

Planned caesarean section may increase the risk of the following in women:
^longer hospital stay hysterectomy caused by postpartum haemorrhage
cardiac arrest.^

To the OP. You're midwife may be right / she may be wrong. Its totally dependant on whether your Trust choose to change their policy or not. If you are set on getting an ELCS, you may get one easily, but equally you may still need to fight for it. You need to be aware of the reality being very different to what the newspapers are trying to make out.

PS. The risks above are based on the PLANNED method of birth (either planned VB or ELCS).

Therefore the risks for a VB include instrumental deliveries and EMCS. The risks for a ELCS only include ELCS.

Induction does tend to increase the risk of an instrumental delivery in a round about way.

Inductions are more likely to end p have the synto drip, the drip increases the chance of wanting an epidural. An epidural increases the risk of an instrumental delivery.

Saying that it's not unusual for someone having their first baby (sorry I'm not sure how many weeks pg you were when you lost your first baby so not sure whether the birth would count purely from a biological aspect) to not push so effectively that they end up having a ventouse or a forceps. Whereas when it's your second delivery it is much more common to only need to push for a much shorter time and less likely to have an instrumental delivery. And that still counts if you had an instrumental for your first.

So if youre having an epidural anyway, having to be induced doesnt itself increase risk of instrumental delivery?

No.

Thanks, good to know.

shag I'm not asking for them to promise instruments won't be required. Just that if they are I would really prefer an EMCS if it is in any way feasible.

Am facing a similar dilemma here and am definitely going to opt for an elective CS next time around. Luckily we're moving to the USA in January so at least I'll have a choice in the matter.

DS is only 6 weeks old(!) so it's early days but I had a full 'cascade of interventions' experience with his birth and it ended in forceps delivery and episiotomy. The most terrifying moment was towards the end of my 36 hour labour when DS was not turning and showing signs of distress. The only option was either forceps or an EMCS. I knew that an EMCS would be much higher risk for me and the baby as DS was already so far down the birth canal that he would have to be pushed back up to be delivered via CS so agreed to forceps. Thankfully DS turned at the last minute so the forceps was lift-out only, not rotational, so he was born without a mark on him.

I've been relatively lucky and the epi has (so far, fingers crossed) healed fine but the first couple of weeks after the birth were pretty awful. DS was also fine, compared to many forceps-delivered babies, but the risk of something going wrong with him at the last minute in labour really terrified me so I just can't face that again. From all the medical evidence I've read, an ELCS is much safer for the baby compared to a prolonged labour and instrumental delivery. The risk to the mother of a planned CS is mainly that of uterine rupture in future pregnancies (not an issue if you don't plan on having more after the next one) or of haemorrhage but that's very rare.

If anxiety regarding your baby's wellbeing is the key issue for future pregnancies, you should be entitled to request an ELCS based on your psychological well-being, I would have thought? Keep pushing for what you want anyway - you have every right to insist on the birth you want.

Thank you for all your replies.

At the moment I want to push for an ELCS before getting pregnant again, I don?t think I could go through a forceps delivery again, unless I know for sure that even forceps is safer for my baby than an ELCS. This doesn?t seem to be the case though?

As for the recovery, it took me weeks to recover after the birth, I was in agony, couldn?t go up the stairs, walk or sit properly, and I needed DH to pick DS up and hand him to me for feeding.

Nicey,this is what my midwife also said, that the guidelines were reported very badly in the press and she thinks the consultants at my local hospital would refuse to do a CS unless medically indicated, but if I feel that I really want/need one, she would support me. As she is the counsellor midwife, they might take this into account, although again they might not. It just pisses me off that a woman?s mental state is not acknowledged ? I?m more than my cervix FGS!

I?m afraid I didn?t understand what you mean with the NICU admission (and it might be my baby brain, sorry). Did you mean that there is a bigger risk for babies born by ELCS to be admitted to NICU? But you are quoting that Planned caesarean section may reduce the risk of the following in babies:
neonatal intensive care unit admission.

InMyPrime, it?s horrible isn?t it? That feeling that you have to choose between two risky situations, and it?s all about your baby, and not much of a choice in fact? After not progressing for a while, and realising that I had panicked and my body had shut down, I was begging for a CS, but they refused. After a few hours DS became distressed and I was told we got to the point where a CS would put him more at risk than an instrumental delivery. I knew this all along, I knew that my body couldn?t give birth naturally, and not because of the pain, but the anxiety, yet no one really listened to me. Anyway, to cut a long story short, I just wanted to say that I know exactly how you feel, and that fear of something going wrong at the last minute stayed with me.

Beaver, good to know about second babies, although DS is actually my second. I had to go through labour with my first baby at 23 weeks, so I don?t know if this counts as a ?proper? birth or not.

bankholiday, I don't know if this varies a lot depending on your local hospital policy or individual consultants. I had a forceps delivery and third degree tear with my first baby, and at a routine follow up with the consultant she said it was my choice if I wanted an ELCS in any future pregnancies. She said this was if I wanted to avoid the risk of further tearing, but also because some women had such a traumatic birth experience in this situation that ELCS was a much better option for them. I actually hadn't had a particularly traumatic experience despite the forceps and I decided against an ELCS and had a very straightforward and quite pleasant second birth, but I appreciated being given the choice.
Could you request a follow up appt. with the consultant responsible for your care and discuss with them that you would like an ELCS?

Did you mean that there is a bigger risk for babies born by ELCS to be admitted to NICU?

Correct. I copied and pasted from the NICE document. Its actual seems to be an error in the document itself! (Double and tripled checked this - definitely seems to be an error on page 64 which is why these are still guidelines)

The actual figures are:
13.9% of babies admitted following an ELCS

6.3% of babies admitted following a Planned VB inc instrumental deliveries and EMCS (Though it IS worth noting that if you end up with a EMCS then the figure for that is 35% of babies born in this way which really does show where the risk is carried - not through vaginal birth)

So whilst the recommendation is to discuss with women that a planned CS carries more risk for NICU admission - if you look at the actual figures, all the risk is stacked up in the EMCS. If a planned VB goes ok, it does makes a VB seem to look great compared to an ELCS. If it ends up as an EMCS then the risks seem to skyrocket. Thats the gamble. (It doesn't provide a breakdown for forceps deliveries unfortunately).

For all the other risks for babies theres no conclusive evidence either way for ELCS or Planned VB being better, though NICE themselves do point out there is no data for medium or long term problems. And those figures are only for women who have had one baby - if you decide to have more babies then the risks could be different.

So from what little information they have, the suggestion is that a ELCS does carry more risks for the baby than a VB.

(It covers NICU admission, Hypoxic-Ischemic Encephalopathy, Intracranial haemorrhage, Neonatal respiratory morbidity (intermittent positive pressure ventilation, transient tachypnoea, endotracheal tube insertion, pneumonia), Neonatal mortality, Apgar score at 5 mins < 7)

Yes buy saying that greater percentage of El LSCS babies are admitted to SCBU doesn't mean the EL LSCS is the cause. You've got to factor in how many of those babies were already comprimsed to some extent hence the decision for an el lscs.

"Beaver, good to know about second babies, although DS is actually my second. I had to go through labour with my first baby at 23 weeks, so I don?t know if this counts as a ?proper? birth or not."

From a biological aspect only then no I probably wouldn't count it as a "proper" birth. The size difference between a 23 weeker and a term infant is vast and the amount of dilation and pushing needed for the former isn't anywhere near as much as for a term infant.

Those NICE figures are quite ambiguous, NICEyNice - they seem to confuse correlation and causation. Surely the reason that NICU admissions for babies delivered by ELCS are higher is because Caesareans are generally only planned in the UK when there is a medical reason to do so, and that medical reason can often be an issue with the baby that requires early or prompt delivery? I'm thinking, for example, of threatened placental abruption, where the placental function isn't optimal for some time and this is picked up in a routine scan so delivery by a planned Caesarean is immediately scheduled to prevent further harm to the foetus or a full abruption. Cases like this would bump up the rate of NICU admission for babies delivered by ELCS but the ELCS is not the problem or cause of that.

Anyway, the advice I've had from the obstetrician I was seeing ante-natally was that ELCS is safer for the baby and the health risks to the downside are all for the mother, as mentioned in my post above. I think the lowest risk scenario for the baby is vaginal delivery with a 'normal' labour i.e. no complications but that's not an outcome that can be planned or guaranteed so ELCS is the next best thing as forceps and EMCS are definitely more risky for the baby than ELCS. Forceps delivery is not widely done in countries with private healthcare, e.g. the US, for that very reason due to the risk of doctors being sued due to causing brain damage or other issues for babies delivered instrumentally.

Anyway, bank holiday, I've looked at the medical evidence and I'm pretty happy to go with ELCS next time around. I feel I escaped by the skin of my teeth with DS so I'm not willing to try again! I hope you can work with your midwife counsellor to persuade the medical system to let you have the delivery you want next time too .

I had a forceps CS so I'm afraid that you can't say it is Instrumentation or CS. The two are not necessarily mutually exclusive.......

You are at much reduced risk of a forceps delivery after a previous vaginal delivery.

A forceps birth is the best thing at that point in time if the baby is deliverable by forceps (ie better than an emergency CS). If you could know in advance that forceps was going to be required then I think that an elective CS is better for the baby. A normal vb would be the 'best' option, but obviously that cant be guaranteed.

Ds was admitted to nicu with respiratory distress syndrome following an elcs. His consultant at the time said that she saw a lot of babies in there with breathing difficulties following electives, specifically, because a) if there are any slight inaccuracies with the date, then the baby can be born pre the recommended 39 weeks, and b) the baby has not been squooshed through the birth canal (obviously the case with all cs) so fluid can remain in the lungs and c) they have not been prepped for birth by labour.

Sorry meant to add that the reason for my cs, was due to previous damage to myself, nothing to do with what was happening with ds.