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.

Windywoos,

May I ask if you already knew the OB who delivered your baby and took the decision to use ventouse and forceps? Its very unlikely to know the doctor delivering your baby in an NHS hospital, but perhaps you went private.

If you didn't already know the team of HCPs, I'm curious as to how you built this formidable level of trust in them in such a short while? You keep saying you trusted your doctors and I'm just wondering about what made you put such immense faith in them?

Lastly, your premise that forceps wouldn't be allowed if they were unsafe is incorrect. There are several drugs, several procedures that are known to have many risks. Yet their use continues despite global concern.

Whether you accept it or not, assisted and operative VBs are the leading cause of birth injuries for babies and women- if you actually read the links I've provided and look for some of your own, you'll know. Just because you got away with no long term damage doesn't mean every women will be as fortunate. Think about it before "recommending" something like forceps.

Mybrainisthinking,

Your assumption that at the stage where ventouse is required, the head will be pushed back into the birth canal for a CS is incorrect.
When ventouse and forceps fail, CS is performed. In none if those cases is the head pushed back- that manoeuvre is done very rarely in cases of SD.

The purpose of using ventouse/forceps is to make the baby crown- if that isn't accomplished, they move on to CS. So think about it- if the head hasn't even crowned, why and how will it be pushed back?

It is perfectly acceptable to refuse ventouse and forceps and move on to a CS.

I had a forceps delivery this time. I was terrified of the epistiotomy and yes it hurt for a while after but it was so so so so so much better in terms of recovery than with daughter 1. I could walk for a start. And twist.

i also still feel that I "gave birth" as I still pushed while the obstetrician "pulled". No it wasn't the natural hippie birth I wanted, and I was scared about going into theatre but the birth for me was so much better than being cut open with the c section.

Am I the only person who is a little uncomfortable about some posters posting with a tone that implies they are an expert in obstetrics/birthing when they are unlikely to be?

I thought this was a thread asking for personal experiences.

Sorry OP, not meaning to hijack...

usingapsyeudonym,

Are you saying that unless someone pushes a baby out, she hasn't given birth?!

There are plenty of reasons to avoid a CS, but associating it with not giving birth is a bit unhealthy IMHO.

I also wonder if being "cut open" is so bad that women actually prefer to risk incontinence, prolapse and fistulas instead.
I've had two abdominal surgeries, and while they weren't pleasant, I'd still prefer them to a forceps birth. I value the health of my pelvic floor far too much.

"Am I the only person who is a little uncomfortable about some posters posting with a tone that implies they are an expert in obstetrics/birthing when they are unlikely to be?

I thought this was a thread asking for personal experiences.

Sorry OP, not meaning to hijack..."

Yes!!! Totaly with you... this was quite supportive as a thread but it has become a bit sidelined by debate which would be best off on another thread i think

Dance - no I wasn't saying that. I was saying that for a long time afterwards I felt like I hadn't given birth. It's a thread asking for personal experiences and all that.

I completely agree with a c section in an emergency but having had both a c section and a forceps birth the forceps was completely fine, just had to recover from the stitches, which an awful lot of women end up with in "natural" labour anyway. Major abdominal surgery took a lot longer for me to recover from. Particularly important for me was being able to look after my toddler after my second birth which I have been able to do as I have been able to walk/twist/cuddle/etc which I couldn't after a c section. Pelvic floor etc all fine here!

Just my experience having experienced a c section 3 years ago and a forceps delivery recently.

BUt to the OP - I recovered from both and both produced lovely lovely daughters so whatever method you go for it will be overshadowed in time to come by your child :)

Actually I disagree with the others who are saying that research links and debate about the morbidity of forceps shouldn't be posted here. The OP is seeking info about one method of delivery because she is concerned about it. Whilst personal anecdotes are useful, it is also helpful to have some 'harder' info about the available evidence.

It's better if they are posted objectively though, with actual links.

Sorry, I think I'm reading a different thread or something . There are links above aplenty, from which the person posting them has drawn her own conclusions, which are different to many of the personal experiences on this thread. The OP can look at those and form her own view surely? No-one is totally objective, that is impossible .

Dance like the wind

You said :Your assumption that at the stage where ventouse is required, the head will be pushed back into the birth canal for a CS is incorrect.
When ventouse and forceps fail, CS is performed. In none if those cases is the head pushed back- that manoeuvre is done very rarely in cases of SD.

The purpose of using ventouse/forceps is to make the baby crown- if that isn't accomplished, they move on to CS. So think about it- if the head hasn't even crowned, why and how will it be pushed back?

It is perfectly acceptable to refuse ventouse and forceps and move on to a CS."

Your advice is incorrect and potentially dangerous. There is movement of the babies head prior to crowning. A CS at the point of where a forceps or ventouse delivery would be considered is more dangerous at that point for the baby than if the delievery can be accomplished with forceps or ventouse.
A woman is at liberty to refuse forceps or ventouse, at which point a CS would then become the next choice, but to present this option as if it involves no additional risk to the baby is wrong. Obviously it is for the pregnant woman to decide which risks are acceptable to her and which are unacceptable, but that decision should be an informed one.

One of the difficulties in this discussion is assessing the various risks. Different people attach different importances to specific risks. Everyone has their own individual decision-making process and people given the same info may reach different conclusions. As mothers, we are also all likely to have emotional reactions to issues related to childbirth based on our own views and experiences.

One common issue in childbirth seems to be that doctors and mothers may assess risks differently and reach different conclusions. This is exemplified by the frequent threads where mothers have been told that they and their baby are alive and that is all that matters. For some people, that may be all that matters. For lots of people we know that other things are also important, for example their experience, how in control they felt, how involved they were in decision-making, their own personal fears and how these were respected or not.

Pelvic floor and anal injuries can have lifelong consequences for some women and for some the potential for these is a significant source of concern or fear. There is evidence that forceps are associated with higher rates of complication for the mother in terms of perineal trauma, tears and incontinence. There is the risk of facial palsy or other damage for the baby. C-sections also have certain risks associated with them including infections, blood clots, bleeding, baldder damage and transient breathing difficulties for the baby. It is major abdominal surgery. Ventouse has risks such as swelling and bruising to the baby's head etc. I think is is perfectly reasonable to want to help the OP understand what the different risks of each situation are, both for her and the baby. There will be hundreds of personal anecdotes on MN of these situations, in each case some positive and some negative.

It's also important to bear in mind that a risk of something does not mean it will happen .

Perhaps the most important thing is to seek out caregivers who will involve the parents in the decision-making (rather than simply telling them what will be done to them, even if they say why), and will respect their individual concerns and opinions? That can be difficult to do in the NHS, where you may have no idea until the day your turn up at hospital who will be caring for you, they may change with shifts and you are unlikely to have ever met them before . It is certainly not unreasonable to put on a birth plan that ventouse and forceps are things you are really not keen on and you would want a discussion about the option of a caesarian instead, as this signals that if the doctor is going to recommend either of these then you have strong views that need to be taken into account. Hopefully that would encourage them to have a full discussion with you.

It might also be worth thinking about what will reduce the likelihood of the need for an instrumental delivery (e.g. avoiding an epidural), and then tracking back what might reduce the likelihood of requesting an epidural (e.g. avoiding induction, considering a birthing unit or homebirth etc). Some people find a birthing partner who has been at births before can help.

catsareevil

Yes, a CS at full dilation does carry certain risks. But they still don't compare to the possibility of brain haemorrhage, cerebral palsy, erb's palsy, and spinal cord trauma which is a direct result of forceps.

I notice people keep focusing on bruising and facial nerve damage, and disregard intracranial haemorrhage, and all the other major risks associated with forceps, including death of the baby.

The truth is, at full dilation, once the baby is not descending, there are risks with ANY intervention.

Not many women understand these things-

1. Failure of ventouse is a contraindication to the use of forceps
2. Forceps are the riskiest intervention of all- for mother and child.
3. When forceps and/or ventouse fail, they perform a CS. By that logic it is never too late for one.
4. Lastly, attempting an instrumental first can often waste precious time, as it often fails.

In light of these observations, an informed woman can most certainly refuse forceps or ventouse to proceed directly to a CS. I'm not saying she has to, I'm just saying she has every right to.

Dance - I'm slightly confused as to how you are interpreting the articles you have linked to in a way to gain insight into a comparison of the risks between a forceps/ventouse delivery and an Emergency CS undertaken at the point forceps/ventouse would be recommended. My observations are as follows:

www.sciencedirect.com/science/article/pii/S0002937803011785
This article is not available in full without payment, which I am not prepared to do for this purpose. One of the opening sentences, however, states that the study considers women who were delivered vaginally, and no reference to CS (at any point) is made throughout the publicly available information.

www.nejm.org/doi/full/10.1056/NEJM199312233292601#t=articleTop
This article does compare the results from vaginal birth (subdivided into unassisted, forceps and ventouse) with those from CS (subdivided into elective and "women in whom the procedure was indicated after labor had begun"). However, the sample population was small (the tabular data relates to just 102 women) and there is no indication of how far labor had progressed in the (9) "women in whom the procedure was indicated after labor had begun".

www.cmaj.ca/content/170/5/813
In terms of data, this article seems to be primarily the author (Mary Hannah) referring back to a previous study of which she was the principle author (the Term Breech Trial), which considered outcomes for singleton, term breech babies with planned vaginal delivery or planned CS. In this article she tries to draw conclusions on how these results may be interpreted for a planned CS vs. a planned vaginal birth of a single cephalic baby - but comments that planning for a vaginal birth includes the risk that an emergency CS may be required, "which carries higher risks for mother and baby". However, these risks are not discussed.

(I'd also like to comment here on your assumption that because research is undertaken by surgeons in large hospitals it is safe to presume they are "skilled". One of the biggest retrospective criticisms of the Term Breech Trial was that the practitioners involved in delivering breech babies did NOT have sufficient skills and experience to do so safely - emphasised by the way reminders had to be sent out to participating units re. the approach they were supposed to be following. I know nothing of the authors of the other articles you have linked to - but my experience and analysis of the TBT in particular has lead me to read all papers critically and to try and work out what assumptions I'm making before I put all my trust in them.)

onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1981.tb01211.x/abstract
Again, this article does not seem to be available in full without payment. The abstract available for free is so brief I'm not sure what conclusions can be drawn - other than that 27 infants who died were found, on autopsy, to have suffered intracranial haemorrhage and that forceps were involved in the birth of all 27 of those infants. However, there were a further 36,397 infants involved in the trial for whom no information is available in the abstract regarding how much assistance was required during their birth.

The authors do make the statement that "The main conclusion is that serious injury to the forecoming head at birth is almost invariably a direct effect of forceps." - but to me that is a very different conclusion to your comment above that "intracranial haemorrhage in the baby is often a direct result of forceps being used". Without knowing how many of the other 36,397 infants were delivered using forceps it is impossible to comment on whether forceps "often" result in this injury or not.

www.pregnancycare.eu/pregnancy/labour-and-delivery
I'm struggling to find the statement "forceps are associated with maximum morbidity", or anything similar on the page you linked to. There seems to be very little mention of forceps other than in that if you plan a vaginal birth you need to be aware that you may wind up with an instrumental delivery. I'm a bit confused as to how this page is supporting your arguments.

Like some others, I'm struggling to see how the links you have posted are supporting your hypothesis that and Emergency CS (performed at the point when forceps or ventouse would be offered and recommended) is safer than proceeding with an assisted vaginal birth. This particular scenario doesn't seem to be considered in any of the articles you linked to . I'm wondering if I've managed to read the wrong articles as you seem very strong in your beliefs and I'm really not managing to see how the information I'm reading could be interpreted in that light - that assisted delivery increases risks, yes. That the use of forceps in particular increase the risks of damage to the pelvic floor and the likelihood of the mother developing incontinence, yes. That an Emergency CS undertaken at the point where assisted delivery would be recommended during a vaginal birth is demonstrably safer proceeding with an assisted vaginal birth - this scenario doesn't seem to be considered.

(Just for clarity, I have no medical training whatsoever. However, I qualified with a BSc and spent 10 years working in an industry where I was required to read scientific papers and form opinions and recommendations that were then presented to clients who needed to make multi-million pound investment decisions. More personally, I did a lot of digging into the safety of modes of delivery of breech babies when DD1 decided turning head down was far too boring - hence my specific knowledge on the Term Breech Trial).

Love
"Oh god, my mother had appalling births with both babies! Induced, incredibly long, forceps, unwell babies... Does that make a difference, windywoos? Somehow I had not considered that it could be hereditary..."

Just to pick up on something :)

Do you know why your mother was induced with both babies? How did your grandmothers get on? There can be an hereditary factor in births, but IMO its a good idea to understand any issues that may have complicated things before getting too concerned about the outcome. Its generally fairly well accepted that induction can increase the likelihood of other interventions, and the risks that go with them. You comment that even after induction they were two long, hard births - I'd be wondering why your mother was induced, how she was induced, how she was treated once she was induced and taking it from there. If you have a family history of long gestation (42+) but your mother was induced at 41 weeks (purely because that was hospital policy), and once induction was started she was given an epidural and told she had to lie on her back with a monitor on and not move, it would suggest to me that her body wasn't really ready to labour and was then forced to try and start the process in one of the worst positions possible - which could explain all the rest.

Most of that is speculation - but its a possible scenario.

For what its worth, my mother's first birth was spontaneous, but she stopped progressing in the 2nd stage and forceps were involved. Her 2nd was very straightforward. I've given birth twice, once a spontaneous birth of a 9lb 12 breech baby, and once a prostin induction of a 6lb 7 cephalic baby (which just needed to get started and then proceeded with no further issues). I certainly didn't experience the problems my mother did with her first birth - its by no means a foregone conclusion that you'll follow in your mothers foot steps as far as birth is concerned.

This is an intertesting review which might be worth a read. I am interested that the American College of Obstetrics and Gynecology recommended training in instrumental delivery to control and reduce the rates of caesarean section. It is also interesting that it lists "relative indications" for forceps where vacuum extraction or caesarean section may be an alternative option, to include:

Delay or maternal exhaustion in the second stage of labour
Dense epidural block with diminished urge to push
Rotational instrumental delivery for malpositioned fetus
Suspected fetal distress

The list of specific reasons where forceps is deemed superior seem to be rarer situations, some involving c-section. I appreciate the use of 'may' is not definitive, but it does suggest c-section may be a viable alternative in many circumstances.

The article is actually about offering women the option of forceps instead of caesarian, but in reading it, it has plenty of info that might be relevant when considering c-section vs forceps from whichever perspective you are approaching the question.

I do think we must recognise that in obstetric practice as with all branches of medicine things are not always as black and white as this or that is best. There are schools of thought and local practices that develop based on local skills or opinions of leading clinicians. It is valid for parents to form their own views too.

PS if anyone can post links to research on the risk/benefits of forceps and/or ventouse vs caesarian when the head is well descended/full dilation then I would be really interested to read them . I'd love to know whether this is something that has specifically been researched or not, and am asking a genuine Q.

There are also 2 Cochrane reviews that I can see that are relevant to this discussion, not sure if anyone has posted the links yet: here and here

Tangle

I come from a family of HCPs. I almost became one myself. Therefore, I have free subscriptions to the websites from which I quote links. I didn't realise, that some people may not be able to access the full article without payment.
Sorry about that.

I don't know how much the article costs, but there is one that clearly does compare assisted births with EMCS and states that forceps are associated with the maximum morbidity. I will search for a free version of the article and post it for you.

Like the others you insist on disregarding incontinence and perineal damage as a risk of forceps. Do you realise how life changing it can be?

You have also disregarded the research paper that states the risks of forceps to the baby-

1. Intracranial haemorrhage
2. Spinal cord damage
3. Brachial plexus palsy
4. Facial nerve damage
5. Possible death

Forceps also put women at a greater risk of developing-

1. Fecal incontinence
2. Urinary incontinence
3. Double incontinence
4. Obstetric fistulas
5. Pelvic floor dysfunction
6. Sexual dysfunction

Perhaps think about that before supporting them so passionately.

In response to the poster who said ACOG is calling for greater training in instrumental births- that news is from 2002. Most medical colleges today(in the US) only provide training in ventouse and CS. Forceps are slowly being relegated to medical history in the USA.

ummm.... ds3 was born by elective c-section and they had to use forceps.

Sometimes you just have to accept that some things are beyond your control.

I think having a healthy sense of faith and confidence in the well-trained professionals involved in your procedure is the best way to have a calm, smooth birth. hth

This article states that sequential use of vacuum and forceps is not advisable

www.sciencedirect.com/science/article/pii/S0002937801985357

101North

The forceps used in a CS are small, outlet forceps. It also involves less of a blind guess, because the doctors can see the head and shoulders of the baby, as opposed to the baby being in the birth canal.
The risk of injuries to the baby us significantly reduced.

Not to mention that in this case the risk to the mother's pelvic floor, or the risks of incontinence due to forceps would not be taken into consideration.

ah, jolly good. Dance

by the by - my ecs was done because of problems arising from ds2's birth which was failed ventouse and forceps delivery.

Sorry OP don't want to frighten you further !

Dance - now I'm thoroughly confused. At no point did I intend to disregard any of the consequences of birth injury (from whatever cause) or belittle them in any way - if my post can be interpreted in that light then I apologise as it was not my intent.

My reason for replying to you was that you are making very sweeping and strong statements that at the point where forceps or ventouse would be recommended a CS is a safer option, and posted links to support that position - having looked at those links I cannot see how you have reached that conclusion. We are must therefore be reading those articles in a very different way and I would like to understand more about how you are interpreting them so that I can, potentially, reconsider my own interpretation.

I completely agree that forceps increase the risk of injury (of many types) to mother and child in comparison to a straightforward vaginal birth or a planned CS. But as you yourself say, once you get to a certain point in birth there are risks whatever you do - and to this point I have not seen any research that compares the risks of assisting a vaginal birth vs. moving to an emergency CS.

Further, you say I've disregarded a paper that states the risks of forceps to the baby - please can you advise which research paper this is? And I'd like to second MoTeaVate's request for any research that compares risks/benefits of assisted vaginal birth vs. CS once the head is well descended - as this seems to me to be the issue at the core of the discussion :)