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.

It is mentioned in the rcog leaflet linked to below, though they give a lower prevalence rate.

Would be interested to learn of Dancewiththewind's credentials......

Or even Dancelikethewind

Sorry

I can't believe the rate of anal sphincter damage is as high as 30% for forceps deliveries. A third degree tear is uncommon. Nowhere near as high as 30% where I work, off the top of my head I would say well under 5% of forceps end up with a third degree tear.

Again Viva I totally agree (based on working in a 5000 deliveries per year unit).

THIS RCOG leaflet for patients mentions nothing at all about it - www.rcog.org.uk/files/rcog-corp/uploaded-files/PIAssistedBirth2007.pdf

All it mentions in terms or risk to babies is "Forceps can leave small marks on the baby?s face. These will disappear."

As someone who has lived forty odd years with permanent facial nerve damage thanks to my own forceps birth, I beg to differ.

laluna

I'm happy to share them with you. I attended medical school for 3 years before I had to quit due to personal problems.
I had no money to continue with med school, so I did a course in mathematics on scholarship and hope to pursue an MBA soon.

I volunteer in several hospitals on my trips to Asia, South Africa and USA.

Where are you getting the 30% figure from Fruitybread? The only one I can see is in the ScienceDirect link and is this one: The incidence of worse bowel control was nearly 10 times higher in women with fourth-degree lacerations (30.8%).

So if you have fourth degree lacerations you're more likely to have problems with bowel control. Not you've a 30% chance of having a fourth degree laceration.

I fully realise I may have missed a stat somewhere - there are a lot of them in the links, but 30% sounds weirdly high, so I started to dig about for it.

Sorry- from MoTeaVate below, earlier today. I may have misunderstood (or she may be wrong) - but she posted this in response to DLTW: -

"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."

viva

Here you are:

This study states that 8 out of 10 women undergoing a forceps delivery had anal sphincter defects.

www.nejm.org/doi/full/10.1056/NEJM199312233292601

this link from RCOG states that 9% of women delivering vaginally develop third degree tears.

www.rcog.org.uk/womens-health/clinical-guidance/third-or-fourth-degree-tear-during-childbirth

That isn't a small number. About 9 in every hundred women who tear develop a third degree tear or worse. Take into account the number of women who give birth each year and you'll have a huge number of women suffering from third degree tears.

That is what the study Dancelikethewind linked to says, yes fruitybread. I did not critique the methodology or sample size of that study, so no idea how 'good it is, or what other studies say. The RCOG figure is 8-12 per 100. I haven't followed up their references, what with it being Christmas Eve .

Thanks Dance - that's interesting. So no formal obstetric/midwifery experience.

All of the research studies are very well but surely evidence based practice is a more useful basis? I have delivered about 700 babies so by your stats that's 63 third degree tears. My personal delivery register confirms one third degree. ?????

The first paper that you linked to relates to sphincter defects apparent on specialised testing, rather than that that is apparent on clinical examination.

3% of women in this study had a 3rd or 4th degree tear.

The results of this study are in some ways surprising eg despite the very high rates of sphincter damage noted eg overall 35-44%, not one of the women who had a ventouse delivery had sphincter damage.

laluna

Did you read my full post?

I was in med school for three years with an intention to be an OB. I now volunteer in maternity wards overseas.

Anyway, I don't know or care why your hospital seems to have recorded only one third degree tear so far. You might benefit from a mathematical concept called variation in sample size though ;)

I posted the figures quoted by RCOG, I didn't personal,y conduct the research. If you have issues with the 9% figure take it up with RCOG, not me.

Yes I did read your full post and note that you do not have formal midwifery or obstetrics qualification. You clearly have a flare for research and mathematical analysis. I have knowledge, skill and experience as a registered practitioner. The info I quoted was 'only' from my personal birth register - nothing to do with my hospital or the RCOG or complex research studies and analysis with or without critique. Despite your apparent interest in this, I am sorry that you dont care hope it highlights the difference between theory and practice.

Sorry for the lack of sense at the end - pressed wrong button. I just feel that it is appropriate to balance all forms of information - not just those spouted in medical journals. Experience does count for something hence why I am able to deliver a baby without sustaining 3 degree perineal trauma.

laluna

Generally, in three years of med school with an intention to be an OB, one does get what you call 'formal training'. ;)
I've also attended several births on my volunteer trips.

Nevertheless, my suggestion to you was to take the matter up with RCOG. They may be able to better explain why their statistics don't match with your hospital's, because you seemed very concerned about that.

Lastly if I were you, I wouldn't take the credit for only one third degree tear;) I'm sure they taught you that there are very few surefire ways to prevent them? They cannot always be predicted and they often just happen. If a woman doesn't sustain a third degree tear, it depends on a lot of factors - it isn't a feather in your cap.

The only thing on my birth plan was "no forceps" - unfortunately DS turned into an OP position as I became fully dilated so I ended up having a manual rotation and lift out with low cavity forceps. After 2hrs of involuntary pushing, having the spinal anaesthetic put in was blissful, and DS was born on the first attempt with the forceps (I was prepped for an emergency c section if it had failed). He had a graze to his forehead and a bloodshot eye, but they were gone in a week.

I would say keep an open mind, I always thought I would never agree but at the time I put my trust in the drs and midwives looking after me and I would have done anything for my DS. Good luck!

The rcog don't quite say that 9% of women have third degree tears. They say that upto 9% of tears are third degree or fourth degree. So it's up to 9% of 90%. I'm crap at maths but that's what about 7%? So slightly less, but still surprisingly high. I'm sure we keep stats at our unit and I'm going to try and find what our rates are, I reckon it's going to be significantly less than that.

www.gpnotebook.co.uk/simplepage.cfm?ID=x20050606103654356350

Here states that occurrence is between 0.5% and 2.5% of vaginal deliveries that have a third degree tear.

www.nuh.nhs.uk/qmcmaternity/Documents/1221v10911_Third-fourth%20degree%20pereneal%20tears%20during%20childbirth.pdf

Here says 2% as well. I'd agree with these figures more than 9%.

viva
it depends on the sample size and demographic. I imagine that in some hospitals at some times it would be less than nine per cent at other times in other areas, in a different demographic it may be much more.

I doubt that RCOG would put a figure that wasn't well verified on their website. When they say up to 9% , I'm sure it means that in some sample sizes the occurrence may be 9%, whereas in others it may be less.

BTW, it isn't 9% of 90%. It is true that 90% of women tear, but the 9% is a separate,independent statistic. It simply means that out of every 100 women who tear, up to 9 experience a third degree tear or worse.

I was talking about cases similar to SpannerPants's.

Once you're being prepped for an EMCS anyway, I imagine it may make sense to ask them to skip risky interventions like manual rotation, forceps etc. and proceed directly to a CS.

Reason being, that since you've been prepped for a CS anyway, the extra time the CS prep takes is no longer a reason to refuse it. It also indicates that the HCPs themselves feel that an attempt at instrumental delivery may fail. If that happens, it actually wastes more time.

That's what I'm saying, 9% of women who tear is not 9% of all women.

I'm working on the pn ward tomorrow, it's a 50bedded ward, so by the rcog figures I should expect there to be about 4 women with 3rd degree tears......from experience I'd be amazed if there was more than one and to be honest having one is unusual. I did look after a woman with a third degree tear last week and it was so long since I last saw one I had to look at the protocol to remind myself how many days she needed antibiotics for.

At the risk of this thread becoming entirely circular the reason why people may not opt to do that is that at that point the CS is a more risky option than the instrumental delivery.

My forceps birth had me prepared in case of c section too and I was areally nervous but i pushed on my first contraction, she pulled and the head came out!

Yes I have stitches but at 2 weeks later I am more or less fine. So very very different than still struggling to walk, cough, laugh, etc after a c section, not being able to drive etc. baby completely fine - no monitoring at all needed. Agpar 9 and 10.

All went amazingly well, I still helped to push and had her delivered onto my chest. I really really cant believe how much easier my forceps birth has been over my c section!