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.

Dancelikethewind

You have been repeatedly told by various people on this thread that you are giving dangerous and incorrect advice. Does this not encourage you to consider your position?

"Most women live to tell the tale, but it is a tale of incontinence, sexual dysfunction or brachial plexus palsy. Just surviving the process is not enough."

Most women? So you fee the need to emphasise that over 50% survive? Thats lucky then, but the ones that do have incontinence, sexual dysfunction or brachial plexus palsy? Funny I have had a forceps delivery, and suffer none of the above. Astonishingly even my brachial plexus got through unscathed

Copied and pasted from the top of the general health board, might be worth reminding folks;

Mumsnet has not checked the qualifications, experience, or professional qualifications of anyone posting on Mumsnet Talk and cannot be held responsible for any advice given on the site. If you have any serious medical concerns we would urge you to consult your GP midwife/obstetrician

Viva

Really? You've never seen instrumental deliveries cause any kind of damage?
How long have you been an HCP?
Nevertheless, thank you for accepting that those are risks involved with instrumental births. Your obstetric unit may be blessed, but research shows that the above complications do in fact occur.

I just have one question for you.
It is normally suggested that forceps deliveries be performed in theatre with the mother prepped for a CS in case forceps don't work. How is it wasting time to proceed directly to a section then? Unless the doctor is neglecting protocol by not making arrangements for a CS before attempting an instrumental birth. The preparation for forceps also requires time doesn't it? Catheter, stirrups, sterilisation, anaesthesia, etc.

Congrats catsareevil! you didn't suffer complications!

I meant the baby's brachial plexus btw. Just shows how much research you've put into all this.

So you're happy with forceps then? Good. Ask for them next time as well. Just don't try to imply that your not suffering complications means that no one else will.

I'm not implying that. And I suspect that you know that.
I'm also perfectly aware of where the brachial plexus is located. I wasnt sure from your post if you were.

From my reading of the RCOG guidelines linke to above, it is not normal for forceps deliveries to be performed in theatre, only those considered higher risk:

"Operative vaginal births that have a higher risk of failure should be considered a trial and conducted in
a place where immediate recourse to caesarean section can be undertaken.
Higher rates of failure are associated with:

• maternal body mass index over 30
• estimated fetal weight over 4000 g or clinically big baby
• occipito-posterior position
• mid-cavity delivery or when 1/5th of the head palpable per abdomen."

I seriously doubt this would even be the majority of cases.

"Most women live to tell the tale, but it is a tale of incontinence, sexual dysfunction or brachial plexus palsy. Just surviving the process is not enough."

From the risks I listed in my post this morning, it is clear that these things will not apply to "most" women who have had a forceps delivery.

You are being v misleading.

I've been a midwife for seven years.

"It is normally suggested that forceps deliveries be performed in theatre with the mother prepped for a CS in case forceps don't work. How is it wasting time to proceed directly to a section then?"

Well for a start I thought we were talking about ventouse as well. Where I work a ventouse will always be done in the room and if the Dr is confident that they're going to get the baby out then a foceps will also be done in the room. If I think we're heading the way of an instrumental I'll call the Dr and while waiting for the Reg to arrive I'll put the woman's legs into stirrups (takes about 30secs) and I will have the instrumental trolley and ventouse machine outside the door. Dr comes in, quick introduction, does a VE, says yes we're doing ventouse or forceps, I shove trolley in the room while Dr is emptying bladder, draw up lignocaine and inject local (takes a minute), apply forceps/ventouse (less than a minute), wait for a contraction and pull. We can have baby out in less than 5 minutes.

If we're going for a section we need to call everyone, whole theatre team. We don't have a theatre team on the labour ward. Not ideal I know, but thats how it is and I can't imagine that we're the only hospital with this. It can take at least 5 minutes if not longer waiting for everyone. And this is imagining the theatre is free, we only have one. I did a ventouse with a Dr the other day who started worring halfway through we're going to need to go to theatre and had to tell the Dr that theatre wouldn't be ready for 10 minutes. So when anaethetist gets here there's the whole consent we have to go through, someone has to cannulate and take bloods, push bed down to theatre, check list to run through, I need to go and change into scrubs, have to get scrubs for partner and get them changed, into theatre. Spinal can take well over 5 minutes to site, obviously they'd do GA if in a real hurry. But risks involved with GA both to mum and baby so prefer not to even if it wastes time doing spinal. Scrub nurse and Drs need to scrub up.

You're looking at 15-20 minutes from decision to knife to skin and thats a best case scenario. This is how it is in real life from someone on the shop floor who sees it day in/day out. Where with a ventouse/forceps in the room baby can be born within 5 minutes of decision being made.

MVT,

Here you are-

www.cmaj.ca/content/166/3/326.short

The above research shows that forceps are the highest risk factor for anal sphincter lacerations and fecal incontinence.

www.sciencedirect.com/science/article/pii/S0002937803011785

The above article states that the prevalence of urinary and fecal incontinence is most common in women undergoing forceps deliveries.

VLB,

What happens if the forceps/ventouse don't work? Doctors aren't God, they may 'feel' they are confident, but instrumental deliveries don't always work do they?

I've seen a forceps delivery being performed, it took them at least ten minutes to catheterise, sterilise the instrument, put her kegs in stirrups, cover her with sterile drapes, administer an epidural. Local blocks in the vagina are not effective pain relief for forceps.

And barring extreme emergencies, how much of a difference is 5-7 minutes going to make? If an instrumental birth allegedly takes 5 minutes and a CS takes 10-15 ( keep in mind it takes you that long because by your own admission you don't have a theatre team on ward).

Unless it's a matter of life or death, asking for a CS instead of forceps (not necessarily ventouse) is not unreasonable.

My experience of having a forceps delivery matches viva's experience of attending them. All done in the room with a local and gas. I doubt it even took 5 minutes.

I said a section takes 15-20 minutes so thats a difference of 10-15 minutes. Not sure where you got 5-7 minutes from.......

Like I said in one of my earlier posts, there will be some births where the 10-15 minutes won't make a difference, there will be others where it will make a significant difference. I think if you have a Dr telling you that the baby needs to be got out and got out now and the safest/quickest way is for an instrumental and there isn't time for a section you have to trust that they know what they're talking about. I do agree that having a blind faith in professionals is not always right but there are some times when it isn't appropriate to argue and you just have to pray that they're a good Dr. Most of them are.

I'm happy that you've seen one forceps being performed. I'd say that I've seen a few hundred. I can assure you that a local block can be a very effective method of pain relief for a forceps delivery. Not for all forceps, but for a low forceps delivery then yes it is. Where the baby is higher this is a case where a forceps would be done in theatre and a spinal block would be done.

I have never seen a failed instrumental delivery in a room. Every time a Dr has attempted either a forceps or a ventouse in the room it has been successful IME. The only times I've seen a failed forceps has been in theatre, the reason we're in theatre is because the Dr wasn't confident that it would be successful.

VLB,

I was mainly referring to mid forceps and high forceps. Those deliveries require spinal blocks and are normally performed in theatre.

So my point was simply this- if you're being prepped for a CS and taken to theatre anyway, it may not be unreasonable to ask that a CS be performed directly without attempting an instrumental. If the instrumental fails, it wastes more time.

As for outlet forceps or ventouse, they are often quicker than a CS as you said and are in certain unfortunate cases unavoidable.
Although, in the USA, women are often given a choice between ventouse and CS when intervention is required. At many hospitals such as Westchester Hospital in New York, and Cedars Sinai, only outlet forceps are used in extreme emergencies. Mid forceps and high forceps are banned.

I agree, and think I actually said that in my first post.

"There can certainly be times where if the Dr wants to do an instrumental but you'd prefer a section then there would be enough time and baby would be in a position where its safe to do this"

However if the Dr said they were confident they could get baby out in the room with a ventouse or forceps with local anaesthetic then I wouldn't be arguing for a section.

"forceps are the highest risk factor for anal sphincter lacerations and fecal incontinence."

Yes, that is true. I do not disagree.

"the prevalence of urinary and fecal incontinence is most common in women undergoing forceps deliveries."

Yes, OK.

Neither of these statements means that most women who undergo a forceps delivery will experience any of these things. Your logic is seriously flawed and not supported by the data in the links you have given.

Something can happen most frequently with one mode of delivery, yet still only affect a small proportion of those experiencing that mode. You have shown no statistics that indicate that any of these things happen to most women experiencing forceps delivery.

For example, in the first study you cite 251 women out of 949 suffered some form of anal incontinence (stool or flatulence), i.e. one quarter. Most of these were not women who had forceps deliveries, some were those who had c-sections. Among the 74 women with forceps-assisted delivery, none of the 51 with an intact anal sphincter had incontinence of stool, as compared with 3 (13.0%) of the 23 with sphincter lacerations. That is 3 out of 74 women who had a forceps delivery and suffered stool incontinence, i.e. 4%.

The rate of anal sphincter lacerations in the forceps group is 23 out of 74, which is just over 30%

For neither anal sphicnter lacerations nor fecal incontinence are these proportions the majority of women who had forceps deliveries as you claim.

I am not denying that a 30% sphincter laceration rate is concerning and may be serious for the individuals involved. But, it is not the majority of women undergoing forceps deliveries.

You know, I made a comment earlier about the UK context. Let me expand on that a little, as this thread has been sent down a major diversion by one person mis-interpreting scientific studies.

Michel Odent argues that the conditions should be right for normal straightforward vaginal delivieries in most women and then that if complications occur clinicians should move swiftly to a caesarian. The thing is, at the moment the way women labour and give birth in hospitals in the UK often does not give them the optimal conditions for achieving straightforward vaginal delivieries. I believe this is the model that operated at Pithiviers.

If someone genuinely wants to avoid an instrumental birth, which I personally do not think is unreasonable given the associated risks, then probably the best things they can do is find ways to make a straightforward spontaneous vaginal birth as likely as possible. This might mean, for example, preparing for non-medical ways to deal with the intensity of labour (e.g. using hypnosis), ensuring they have good support from a birth partner, and if possible continuity of care from a midwife they know (in the UK this usually means opting for homebirth or an independent midwife), avoiding as much stress as possible during labour and labouring in a comfortable homely environment, not birthing lying on your back, avoiding induction or acceleration of labour, avoiding an epidural etc etc etc. These things will not always be possible in all circumstances for all women.

Additionally, having a discussion in advance of labour about fear of instrumental delivery and flagging up and documenting your strong preference to avoid it or indeed advance warning that you will not consent to it, may alter the way you are cared for if things do not go to plan. Knowing you would refuse a late attempt at an instrumental delivery might, for example, mean caregivers would consider a c-section sooner to try to avoid a time-critical situation where the baby is stuck. This already happens in a way in homebirths, where midwives are considering transfer to hospital in time for other measures to be taken if there are problems.

Once you are in the situation of having been pushing for 2 hrs and baby is not coming out and beginning to look comprimised because of heartrate dipping or whatever, then as viva says, the instrumental delivery may at that point offer significantly less risk to the baby. You can of course still decline it if you choose, just as you could indeed decline a c-section as well, even if it would be detrimental to the health of both you and the baby.

MVT,

I said majority of the women suffer more serious injuries from forceps than they would have without them. I didn't say majority suffer anal sphincter lacerations.

A significant percentage of women who undergo forceps deliveries end up with incontinence or other complications, which IMO is a reason to refuse them.

Lastly, while I think women should have the right to refuse forceps and ventouse under all circumstances, I don't think they are 'allowed' by HCPs to do that. They are often not asked for consent and bullied into accepting.

The situation you describe is idealistic and not possible in crowded NHS hospitals, although it might be in private hospitals.

I do think it is possible to avoid instrumental births completely by opting for a CS at the first sign of trouble ( as they do in many American hospitals ).
However, this will significantly increase the CS rate, which I don't consider to be an issue, but some people might.

I remember the story Matthew MaConneaghy (sp?) related of his son Levi's birth. The ventouse didn't work and they proceeded to a CS.
So it is a slippery slope IMO. Many times even when a ventouse is suggested a CS is actually a better choice, but you don't find out until later.
Therefore many American hospitals offer women a choice between ventouse and a CS when intervention is needed. To my knowledge, forceps are rarely mentioned. I just feel that if they can manage, why can't we?

I have scanned this thread and don't want to add to the whole instrumental v cs debate. I do wish to add my support and agreement to everything Viva has posted. I am a Delivery Suite sister and have been qualified since 1996. I too have never seen any of the complications listed by Viva.

On a personal note, I was a mw when I had my kids but could fully empathise on the terrifying prospect of an instrumental, particularly having seen loads. My DD was delivered by ventouse for bradycardia and at the time they could have cut me open without any anaesthetic - I couldn't have cared, as long as they did whatever to ensure her safety. I am grateful that this is what my colleague did. The reality, physically, was fine and not at all as anticipated.

Thank you DLTW. Your last post makes a lot more sense than some previous ones, which were perhaps unfortunately worded. Not everyone will agree with your assessment, but it doesn't seem to me an unreasonable view for one person to hold.

The situation I describe may well be unrealistic in many NHS hospitals, however it is certainly very possible in the UK today where a homebirth is planned . For a straightforward pregnancy numerous studies have shown this to be of roughly equivalent safety to the hospital option. Not all births will go to plan, of course, and some women have pre-existing conditions or complications that make a consultant-led unit a safer choice of place of birth, or some need more assistance during labour and will benefit from transfer to hospital. A second choice, which offers some of the same advantages as home is a midwife-led birthing unit. Those that are attached to hospitals have all the more medical options close-at-hand as well, should transfer prove necessary. The other preparations, such as things like relaxation techniques, yoga, hypnosis and ensuring a supportive birth partner are things that are attainable for lots of women, and many find helpful .

MVT,

They might have been unfortunately worded, but I also think some posts were deliberately misinterpreted.

This is interesting:

emedicine.medscape.com/article/263603-overview#a05

The article states that contraindications to forceps deliveries include refusal to consent to the procedure and failure of vacuum extraction.

Something to think about;)

Of course refusal to consent precludes a forceps procedure.

catsareevil

If only.:( :(

Many women are scared and bullied into not only forceps but also unnecessary c sections, inductions etc.

So the rate of anal sphincter lacerations in the forceps group was OVER 30 PERCENT??

Don't see that or anything like it mentioned in the NHS info leaflet. Or the level and nature of injuries to babies. I can't believe this information isn't collected somewhere in the NHS. We deserve to know.