Really, really hate the idea of forceps or ventouse... please share your thoughts on declining them and proceeding to C section instead

[LoveInAColdClimate]

I think I'm probably being a bit silly. I really, really hate the idea of either forceps or a ventouse delivery, to the point where I am considering putting on my birth plan that in the event that either is necessary, I would prefer a C section. I'm not even sure why I loathe the idea so much that I'm prepared to opt for major surgery instead. Has anyone refused forceps/ventouse? If so, why? How did the hospital react? Were you pressured to agree? Has anyone had them and found it not really that bad? Am I worrying unecessarily (and possibly focusing my fear of the birth into this one area)?

Will the hospital always discuss their use with you before doing it? A gradutate of my active birth class was convinced that forceps had been used on her without consent, but she did say she was so out of it that she might have consented without really realising.

TIA.

Laluna, as a fellow midwife can you think of any reasons why figures might differ round the country at different units? I can't, apart from obviously a midwifery led unit would have lower rates of third degrees.

Dances talks about how where I work might have lower rates but other units could well have higher rates. I can't think of any reason for this. I work in an average size consultant led unit, no better or worse staffed than other places. There would be no reason why the women coming into our unit would be less likely to have a third degree tear. We have typical epidural rates, induction rates, etc.

The only influencing factor I can think of that may differ are different doctors. But as the registrars change every year I can't imagine that we always get amazing registrars every time.

I think the other issue of course is how many third degree tears result in serious ongoing problems, such as continence issues or readmission.

My understanding is that if a third degree tear is properly assessed and promptly and skillfully repaired then it's unlikely to cause significant further problems.

MVT,

I searched again- no info on a CS causing intracranial haemorrhage at any stage in labour.

Maybe this will explain my point better. Even if the occurrence increases slightly, the basic risks involved with a CS don't really change no matter what stage it's performed at.

So we can compare breathing difficulties for the baby with intracranial haemorrhage, spinal cord injuries, brachial plexus nerve damage etc. which are the risks involved with forceps.

Likewise, for the mum we can compare the increased risk of infection, hysterectomy etc with the risk of sexual and pelvic floor dysfunction.

I accept that if the fetal heart rate is very worrying and the baby is low enough that a ventouse/forceps can be performed more quickly, then it a woman may prefer to opt for an assisted birth.

viva

For the last time- 90% of women experience some sort of tearing. That's one aspect of the research. Now take all the women who tear, let's say x thousand. Then work out how many have third degree tears. If out of every hundred, y women have third degree tears, we will say that y% have third degree tears. It is not y% of 90%- that would make zero sense mathematically. They may seem logically dependent, but mathematically those are independent statistics.

viva

How do you expect that there will be an identical rate of third degree tears in every hospital?! It depends on so many things- circumstances aren't identical everywhere.
The same doctor might handle the same scenario differently at different times.

It also depends on demographics- some women are more likely to tear than others- genetics, fetal size and weight, the kind of HCP available at the time, etc.
Most tears can't be predicted or even prevented.

I haven't read the whole thread but I am fresh from a ventouse delivery, a few days ago. The issue was that the baby was in the wrong position and needed rotating. I ended up with an intact perineum, a healthy baby out in a matter minutes and no major surgery. Just wanted to throw that in for anyone freaked out.

I would also add that the doctor did a lot of 'manual work' as my DH put it, to prevent tearing. (Not sure exactly what, but he talked about 'stretching and pulling'.) I am willing to believe that a lot of the risk of tearing depends on who is doing it and the level of skill they have.

"For the last time- 90% of women experience some sort of tearing"

Different groups have different rates of tearing.

And most tears are trivial and the vast majority heal without complication.

And of course 100% of women who have a c/s have a full thickness wound through skin, muscle and an internal organ, requiring a large number of sutures.

By the way, I've got propped up in front of me a document from 1993 entitled "the perineum in childbirth" - a survey by the NCT

Among other things, it looks at rates of perineal trauma among first time mothers (who of course have much higher rates than second time mums) according to place of birth.

The figures here are:
Intact perineum:
Homebirth - 38%
Consultant led unit - 17%
GP unit - 18%

A more recent study of outcomes of births managed by independent midwives in the UK found this:

Mothers in the IMA cohort were more likely to have an intact perineum (52.9% v 47.6%; 0.55, 0.48 to 0.64). The incidence of third or fourth degree tears was similar (1.0% v 0.8%), as were Apgar scores.

So - 52% intact. Many more would have had small wounds which may not have needed suturing.

"I am willing to believe that a lot of the risk of tearing depends on who is doing it and the level of skill they have."

Agree!

here

For you Dance. Link to the study on independent midwives I've mentioned above.

DanceLikeTheWind

You state

^LaVolcan
I'm glad you aren't incontinent and the forceps worked for you. Keep in mind that if you had become incontinent (as some women do- some on mums net have experienced double incontinence after Kiellands forceps) you wouldn't have been so glad to have been "spared" a CS. Most women have no way of knowing if the person using forceps on them us experienced enough or not.^

Well, it didn't go wrong, so I remain glad.

By the same token, most women have no idea whether the person performing a CS on them is skilled or not. You assume that a caesarean always goes 100% right and never causes damage to the baby, but this is too in part depends on the skill of the obstetrician.

However, I think it's not worth trying to discuss with you because you clearly do not want to consider an alternative viewpoint to your own.

To go back to the original poster, I can't remember whether this has been said or not, it sounds as though she needs to make an appointment with the consultant or consultant midwife to talk through her fears. I think this would be more useful to her than a discussion on Mumsnet.

For the last time- 90% of women experience some sort of tearing. That's one aspect of the research. Now take all the women who tear, let's say x thousand. Then work out how many have third degree tears. If out of every hundred, y women have third degree tears, we will say that y% have third degree tears. It is not y% of 90%- that would make zero sense mathematically. They may seem logically dependent, but mathematically those are independent statistics.

I agree with this and always have done.

I disagree with your earlier statement when you said 9% of women have third degree tears rather than it been 9% of tears are third degree according to these stats.

I still think it's sad that you seem unable to understand that two separate statistics can be related to each other. You don't just have to look at stats independly. Gosh I covered this in basic gcse statistics.

"For the last time- 90% of women experience some sort of tearing"

What - because you say so?

They don't.

The research into outcomes for independent midwives I linked to shows that they don't. (this research has been peer reviewed and was published in the BMJ - it's perfectly reputable).

You are wrong Viva!

To repeat - the IM's study showed that 52% of women cared for by independent midwives had an intact perineum after birth.

And actually - the NHS figures weren't massively worse than this.

Shagmund - sorry I was just quoting what Dances what saying - should have made that clear. I completely agree with you. However Dances has been telling me off for ignoring statistics that I don't agree with. While she chooses to ignore all the other statistics I've found showing much lower rates.

Whoops! What an arse I am. Sorry Viva!

We've been having a bit of a discussion about the RCOG figures, which I do disagree with. But I've also been disagreeing from a stats side of thing with Dances saying earlier that 9% of women have third degree tears.

I've been trying (but she fails to understand) that the RCOG say that 9% of tears are third degree, which is very different to saying that 9% of women have tears. Because not 100% of women have a tear, only 90% (according to the RCOG). So I'm trying to point out to her that if you want to know how many women have a third degree tear (according to the RCOG) then you have to say that its 9% of 90% of women. She keeps bleating that I'm thick and don't understand that its two seperate stats. I do understand its 2 seperate stats and that the 9% of tears is 9% of 100 tears. But she doesn't understand that you can relate the 9% to the 90% of women and come up with a statistic for how many women have a third degree tear, not just how many tears are third degree.

It just bugs me a bit that she's "laughing her ass off" at me when its her that can't understand basic stats. I really should stop worring about her ineptness though when I'm sure that the stats aren't right in the first place and every other study I've found shows much lower rates. Unfortunately the RCOG don't say where they've got their figures from. As a HCP I therfore do have to dismiss their figures as I can't independently critique the research involved.

Viva

fwiw I know, and understand what you mean.

Hopefully the the OP got the information that they wanted from the thread.

I understand what you mean too Viva. Just taking the stats as correct for the purposes of demonstration (though I know there is another separate discussion about the numbers themselves): 90% of women have tears. 9% of women who tear have a third degree or worse.

So, if you take 100 women who tear, you would expect 9 3rd degree. But we want to know how many from the population as a whole, not just from those who tear.

To work out how many 3rd degree tears in the population as a whole, you need to work out how many 3rd degree tears you would expect in a sample size of 90. That would be 0.09 x 90 (9% of the sample group). That would be 8.1. Therefore, of 100 women, you would expect 8.1 3rd degree tears; 10 with no tearing and the rest inbetween.

That works doesn't it? They are statistics which use different populations, but those statistics can be interrelated. You do not have to keep them as free standing statistics as Dance keeps insisting.

Secondtimelucky,

You gave it right that out of hundred women who tear, 9 may experience a third degree tear.

But as I explained to viva, you don't need to multiply 0.09 with 90 because that's actually been done already.

Let's assume 900 women tear out of 1000. That means 90% of those women tear. Now what is done to calculate the number of third degree tears is this:
See the number of women out of 900 who have third degree tears. Let's say it's 81. Then the percentage of women who have third degree tears(out of those who do tear) will be
81/900*100= 9.
As you can see, there is no point in taking 9% of 90%, because while arriving at that 9% statistic, they've already taken into account the fact that not every woman will tear.

dance

Are you actually for real?

Shagmundfreud,

Your link just proves my point further- different sample sizes show different results.
I'm sure we can find a sample size where none of the women tear, and one where they all tear.

At the end of the day, it still proves nothing. Nobody can have a guarantee that they will not tear. It can obviously be prevented in some ways, but not completely.

The 90% is a statistic quoted by RCOG. I'm assuming they've taken an average of various sample sizes over the UK to arrive at that figure.
It's honestly not something I've come up with myself, so if you've got an issue with it, please email them and tell them to change their statistics to what you feel is more appropriate.

LaVolcan,

I'm not denying that a CS can cause damage to the baby. I'm sure an inexperienced OB may end up nicking the baby.

However, it is just my personal opinion that the risks of a CS are more acceptable (to me) than those of an operative VB.

I'm ok with transient breathing difficulties and a nick for the baby. I'm not ok with intracranial haemorrhage, cerebral palsy and brachial plexus nerve injuries.
I'm ok with staph infection or even a hysterectomy. But I'm quite sure I couldn't live my life with pelvic floor and sexual dysfunction. Or with incontinence.

No, that maths doesn't work I'm afraid.

I agree that maybe it's easier to explain with real numbers rather than percentages or decimals. If you use your figures and have a sample size of 1,000, you have 900 women with tears and 81 with third degree or worse. You are then you are quite correct that the percentage of third degree tears amongst those who tear would be 9%. But to find the total percentage of women who have a third degree tear, it becomes 81 women out of 1,000 (your total sample size)- which is the 8.1% figure I quoted. To get to the percentage for the total population you need to factor back in those who didn't tear at all, and your example misses that step I'm afraid.

"At the end of the day, it still proves nothing. Nobody can have a guarantee that they will not tear. It can obviously be prevented in some ways, but not completely."

No. And if you have a c/s you are GUARANTEED to have a LARGE and FULL THICKNESS WOUND with many sutures. And yet most women don't find this a massive worry, just like most women don't find perineal tears a worry or a problem after birth. (and of course perineal tears - even bad ones - don't put you at increased risk of life threatening complications like scar rupture or placenta percreta in subsequent pregnancies....)

"But I'm quite sure I couldn't live my life with pelvic floor and sexual dysfunction. Or with incontinence."

Most women who have a less than perfect pelvic floor or minor stress incontinence are happy and content and still manage to have a decent sex life and good self esteem.

Maybe this is an issue for you because you're fixated on your genitals in a slightly obsessive and unhealthy way.

I honestly think you'd benefit from doing some reading, thinking and talking on the wider subject of motherhood, maturity and sexuality. Get your mind out of your pants. It'll do you the world of good.

errr, am I going to frighten myself more by reading this thread?

Pregnant with twins, considering a CS.

I had a third degree tear last time, I delivered kneeling up, only pushed when told to, no instruments ever mentioned (though a CS was always a threat, I was induced with an unfavourable cervix), 7lb 5oz baby. I still tore a lot! Instrumental deliveries are certainly not the sole cause of third degree tears. Same for my friend- not sure what position she delivered in, but she had a 6lb4 oz baby and a third degree tear. While I did take a good while to heal from the third degree tear, I don't have any continence issues. I thought I'd have a quick look at this thread, as I'm considering ELCS as been advised that a twin pg, plus old third degree tear (DD only 15 months) and twin 2 breech so may be an assisted delivery.

and while you ladies are on stats, does anyone have any for how likely you are to tear again after a third degree tear?

Not so sure now about reading more yet- will I scare myself more about either option of delivreing these babies?!?!