Forceps or caesarean - which is safer?

[spannermary]

Reading up on way too much stuff as I approach 36 weeks, and have been looking into various interventions.

BUT - in case I don't have a 2 hour natural labour with fairies kissing my feet... If it comes to forceps v emergency caesarean which would you say is less traumatic for mum and baby, with fewer potential complications and risks?

I was never sure whether reading up on things made me well-prepared or panicked!

I'm sure others will be along in a minute with more experience than me, but I do think that you (or your birth partner) needs to listen to what your midwife or doctor says about your specific situation. By all means ask questions and make your wishes known, but unfortunately the choice usually depends on the medical requirements - for example how far down in the pelvis baby is. Minimising trauma for mother and baby will be something that the midwife/doc should take into account.

It depends entirely upon the situation.

I had forceps with DD. I regret it, and wish I had opted for CS but then she was still far enough 'up' for that to be a consideration. I ended up with a 3rd degree tear from the episiotomy I was given to accommodate the forceps extending.

Sometimes the baby is too far down for a CS to be a realistic option, in which case really there's not much of a choice.

It also depends on the type of forceps. Keillands forceps (which they use to rotate baby) I would give consent for over my dead body.

I've never had a CS, and after DD's birth I had a PPH and retained placenta and I found the removal of that very traumatic, so of course that colours my view - if I'd had an EMCS then I wouldn't have experienced the placenta being removed that way, but then not everyone who has forceps has a retained placenta (although an assisted delivery does increase the risk of PPH and retained placenta)

Flisspaps, out of interest, if they suggest using Keillands forceps because the baby needs rotating, and you don't want to consent to it, what is the alternative? Are these sorts of forceps only used at a point when CS is still a possibility?

I would concur with what the others say. I had rotational forceps in theatre. Had an episiotomy which extended into a 4 th deg tear. My daughter also had quite traumatic bruising to her face, it was brutal. She had cranial osteopathy in an attempt to correct the torsion of her head. Personally I think these type of forceps should be banned! I wish I had done the research like you, I would not have consented, but hindsight is great isn't it?

Luckily my daughter is now a healthy 4.5 year old. I have no major lasting damage, but in the future will need an anterior repair as I have both rectal and bladder prolapses.

The next delivery was by elective CS, funnily enough.

I would make sure that you discuss this with your birth partner because at the time I was in no state to make any decision and I dont remember giving consent to anything, although I apparently did.

My obstetrician told me the order of safety was:

1 vaginal birth with no intervention
2 elective caesarean
3 vaginal birth with intervention (forceps or ventouse)
4 emergency caesarean.

He also said that of 100 women aiming for number 1, 50 will end up with what they wanted and 50 will end up with options 3 or 4. So aiming for the best option gives you a 50:50 chance of the two worst options. But I guess it depends on how your labour goes. I've been told subsequently that his numbers are too pessimistic regarding those who end up with number 1 outcome, but I thought I'd share as it stuck in my mind.

I suppose the real worst option is cascading down from 1, through 3 and onto 4 but I guess you just can't tell until you are in the delivery room. Hope you get the birth you want.

But then, I had rotational forceps with my daughter, didn't have an episiotomy but had a second degree tear. My daughter's head was bruised but that went down quickly and she suffered no further effects. Perhaps I was lucky and had a skilful registrar wielding the forceps, but it doesn't always have to be traumatic.

If I had been able to back and do it again, I would have stayed at home longer even though my waters had broken, and refused to be accelerated - which seemed to be more about the labour suite being busy than about our health.

Thanks, guys - that's really interesting. You're all very clear on your attitude towards Keillands/rotational: does that mean you think regular forceps are ok - or just a necessary evil if the delivery is too far advanced for CS?

We are hoping for a vaginal delivery, but I think that knowing about these options and discussing with DH (birth partner) are useful. So I've told him I don't want Keillands/Rotational forceps, and would prefer Caesarean in that instance if it comes to it, and is an option. I've also added it to my birth plan - because chances are neither of us will remember when we're in there!

It's really interesting to see your views on it, Fliss as I know that you are hoping to have a HB this time, so to have you suggest that a CS would have been preferred to forceps has made me think about the nature of different interventions.

And you're right, too babybouncer - research can definitely go too far! I'm trying to be informed but not totally control-freaky, because I know that much of my useful research will come to nowt at the end of the day anyway! It helps me get in the right headspace though, and as a woman approaching 35 who's 4ish weeks away from my first child, I find this level of research helps.

Avoiding the Daily Mail though! (No change there, then!!)

In general CS is the safest option for the baby - its risk to the mother is debatable, but it will definitely compromise the safety and your freedom of choice for subsequent pgs. Hence your attitude to EMCS will be coloured by how many additional children you are planning on - though you shouldn't overstate those risks of course, loads of women have multiple successful births, either VBAC or ELCS, after an EMCS.

I had a stuck baby and consented to a trial of ventouse x3. When this failed I was offered a manual rotation (which simply is 2 hands inside you attempting to twist and move the head back up in my case, so there are other rotational options) and then I had an emcs. I made the decisions in that moment according to recommendations of the consultant. I never thought I'd consent to intervention so it's worth bearing that in mind. I was happy with this. 2nd time round I went straight to emcs but only because I knew the same position = the same problem and intervention was unlikely to help. I'd have consented had I believed it would work.

I should add though, that I had induction of labour as I was 12 days overdue, perhaps she just wasnt ready to come out. I do know that my Mum also had forceps deliveries for me and my sister. I also still believe that you have to trust the judgement of the medical professionals.

Both of my babies got stuck and needed turning! I had trial of ventouse and then emcs with my first baby and we were both fine. With no 2 I had forceps and think they must have been the rotational sort as they were to turn him. We were both fine then, too. The difference for me was in terms of recovery. After the emcs I took longer to recover but the painkillers meant that I never felt more than a little uncomfortable. With the forceps/episiotomy I felt really, really bruised and it was more painful but for a much shorter amount of time. Obviously I can't tell you how my babies felt about it but they both settled to feeding quickly and did not seem distressed. To be honest, I didn't read too much about different interventions before either birth so just agreed at the time. Before my first baby I would have said that I would find interventions difficult to come to terms with. But in the event, I was just so glad that I was fine and so were they. I think it is very difficult to know how you will feel about any of it until after the event, I was just lucky.

KatAndKit As far as I am aware, Keillands forceps are only used to rotate the baby when baby is high up, so yes I would assume so but I don't know that for sure. Neville Barnes forceps are the more common type used to pull baby out.

AFAIK Keillands forceps are banned in some parts of the world, but it is very unusual for them to be used from what little I know.

I had forceps for my ElCS, just to throw that into the mix! He had a tiny mark on his cheek that was gone by the end of the day.

I was not given the choice when it came to it. I was told I was having a forceps delivery, when I refused consent and requested a c-sec I was told no. The registrar was adamant it was safer for me to have the forceps delivery. This time I am going for an ELCS I hope!

Interesting thread. I had a ventouse delivery last time, which wasn't ideal but ultimately not a big deal for me long term, but I definitely had the impression that DS had a sore head for a couple of days and it was impossible to lie him on his back (so therefore put him down at all). Would obviously prefer to avoid next time, but still feel it would be preferable to CS or forceps, circumstances allowing of course.

What leads the delivery team to pick ventouse over forceps? Is it a case of the need to rotate? Or the extent to which the baby has descended? Or just dr preference?

I had mid cavity forceps (whatever that actually means) and I would not recommend it. I wasn't given a choice though. Dd was back to back, but turned before delivery. I had lots of internal tearing and lost 800mls of blood and it took 45 minutes to sew me up. I have a small degree of prolapse, although no significant problems with this. DD was very bruised and swollen but has no lasting effects.
If given a choice would choose an elective cesarean next time, but not sure if that would have been better than forceps after going through 36 hours of labour.

I had 4 day induction last time which ended in forceps delivery despite me requesting cs as exhausted. I would never have them again and am booked for elcs next week for dc2.
I had incontinence problems for weeks afterwards and surgery after 4 months of birth to repair damage. Ds had bruising and deep cuts to his face and head, which became infected. He still has a Harry potter style scar on his forehead at 3 yrs.
I believe that once you are on the conveyor belt of intervention you actually get little choice about what happens next. It's for that reason that I feel in my case an elcs is the way to feel more in control and to manage potential risks.

I ended up with a forceps delivery. However, when it came to it the consultant suggested forceps to help baby (he was showing signs of distress), my DH piped up and said that I'd prefer vontouse and could we try that first. The consultant said they would try and explained that they can only attempt that 3 times and then would have to try forceps. But they did listen to my DH (and my nods and grunts of agreement) and prepped the vontouse, however my DS was a bit too stuck and so forceps were used.

I did think very momentarily that I could ask for a CS but having got to 10cm quite easily I felt i would be ok to do it 'naturally'. I also needed an episiotomy, and my DS had shoulder dystocia and I've got a 4th degree tear. This is rare so chances are this wont happen to you.

Try not to worry, as what you are thinking and feeling now may completely change once you have been in labour for 3 days.

My LO got stuck, and was distressed, so they prepped my for CS, gave me an epidural and wheeled me to theatre, but did say they would try forceps first if I was ok with that. I said to my MW "I can't handle anymore of this, just do the CS and get her out" had been labouring for 24 hours and pushing for 1.5. She advised me to wait till I had the epidural and see what I wanted after that. Had the epi, in theatre, and tried pushing with forceps. Couldnt feel a bloody thing, so dont know how I knew I was pushing but I was. Little help from forceps, a cut mended with a couple of stiches and she was here.

Only 6lb11 too, so not a big baby. In hindsight, I am forever grateful that they used the forceps over CS, as my recovery time was nominal in comparison and didnt involve a major operation. Of coourse, everyone is different, and I do think you are only ever really ready for labour after you've allready been through it.

Go with the flow on the day. Take advice from your MW, and take comfort from the fact that everyone around you is trained to deal with whatever happens during your labour. And, most importantly, never ever think (whatever style of birth you have) that you could have done better, or guilty for the way things turn out. It is a major event, and you should be proud of however you handle it.

When I had a look at studies about a year ago the order was:

1. VB no complications
2. ELCS
3. EMCS
4. VB with complications

although the types of risks can vary (some options are riskier for the mother, safer for the baby and vice versa) and as with all generalisations, it may not apply depending on the individual circumstances of the case.

"He also said that of 100 women aiming for number 1, 50 will end up with what they wanted and 50 will end up with options 3 or 4."

That's with an overall emergency c/s rate of 14%.

And a national ventouse/forceps rate of 12.5%

But healthy, low risk mothers giving birth at home or in an MLU will have a lower rate than this, which will tip the balance of risk.

And look at the figures for your hospital and compare them to hospitals close by. Some hospitals have emergency c/s rates of over 20%. Some have emergency c/s rates of less than 14%.

I also think your doctors point about assisted deliveries being less safe than planned major surgery - there is a huge spectrum of difficulty with assisted births, from the (rare) rotational forceps done in theatre by a consultant with a surgical team on standby, to a little 'lift-out' ventouse done by a registrar in the delivery room, where the baby is just sat there on the perineum, and the mum needs a little bit of help for the last centimetre or so. Most women fall near this end of the spectrum than the forceps in theatre scenario.

It depends on the skill of the operator. For what it is worth, I had trial of ventouse followed by a forceps delivery: both in theatre and prepped for c-section if the forceps failed. Ended up with internal tearing, PPH, transfusion, baby with large bruise on the head and jaundice bad enough to require admission to the paediatrics ward and light therapy. Like you I had done a lot of research and was clear I did not want forceps, but after 27 hours of labour brain was fried and I consented to the above. It took about 3 months to recover to a decent extent and I still have some problems now, 2 years down the line. I wish I had opted for a c-section and this time I am having ELCS. Everybody I have seen, including two different obstetricians, agreed it was the right option given the trauma last time round...

I ended up with a ventouse the first time and a bad 2nd degree tear, although they did only guide her head, no cone head or marks or anything.

With ds I had no assistance and still had a 2nd degree tear so can't really blame tge first one on the ventouse.

Remember that once you are in the thick of it, it is very difficult for either you or Dh to control how things progress and what outcome is - you may be in no fit state to make decisions and your DH may be emotional and may not actually know what decisions he is expected to or should make.

So I'd advise you make a decision one way or the other well before your DD, and clearly set it out to DH.

If I were advising a friend I'd say if you go into labour naturally and there are complications, insist on a CS immediately (don't wait to see, try forceps, whatever). And if the doctors want to induce/speed up labour I'd insist on a CS at that point too. And if I had my time again I'd go straight to elective. I just think that the outcomes of 'not-very-successful' interventions are just too high to take the risk, even if statistically most interventions are 'successfull'

Bear in mind I say that from the very biased viewpoint of having had 6 months of double incontinence with my first child.

My obstetrician has always maintained that the riskiest way for a baby to be born is by means of a forceps delivery. Outlet forceps are not always bad (by that time it is too late for a CS anyway), but she has always told me that as a doctor she would never agree to mid-high or high forceps. These include the dreaded Kiellands forceps of course, but also the Neville Barnes and Simpson's forceps.

I am not entirely convinced by the argument that it is sometimes too late for a CS. Of course if the baby if crowning or the head is already out it is certainly too late! I just keep thinking that if forceps fail ( as they often do ) then they move to a CS. By that logic they could have moved straight to a CS, couldn't they? If anything it would save time and the possibility of having mum recover form both a forceps birth and a major surgery.

My advice to you is to not go by what anyone here is saying because a lot of us will have biased opinions based on our own experiences.

I've looked up some research for you and hopefully this will help you to decide which risks are preferable to you.

www.thieme-connect.com/ejournals/abstract/ajp/doi/10.1055/s-2003-42775
(states that forceps are known to cause brachial plexus nerve damage)

journals.lww.com/greenjournal/Abstract/1984/06000/Birth_Trauma__Incidence_and_Predisposing_Factors.7.aspx
(Logistic regression analysis of fetal, maternal, and intrapartum complications in labor and delivery revealed that midforceps, shoulder dystocia, low forceps, infants greater than 3500 g, and second stage labor exceeding 60 minutes were the predominant events associated with fetal injury)

journals.lww.com/plasreconsurg/abstract/1990/01000/facial_nerve_palsy_in_the_newborn__incidence_and.1.aspx
(states that facial nerve palsy is most common in macrosomic infants or those born with the aid of forceps)

facm.unjbg.edu.pe/revistaspediatria/Clinical%20Pediatrics/2004/Pediatric%20Clinic_51_June2004_%20the%20Newborn%20Nursery%20Part%20II/Management%20of%20birth%20injuries.pdf

^ Fabulous article about birth injuries. From what I could make out majority of the birth injuries had forceps listed as the major risk factor, other than of course fetal birth weight of more than 3500g.

www.sciencedirect.com/science/article/pii/0029784496001512
(lists forceps as a major risk factor for pelvic organ prolapse)

www.sciencedirect.com/science/article/pii/S0002937803005726
(there is an increased risk of anal sphincter damage and hence incontinence with a forceps delivery)

www.bmj.com/content/308/6933/887.abstract
(lists forceps as one of the major risk factors for third degree tears)

I can't imagine why anybody would prefer a forceps delivery over a CS, but I respect that everyone has a different way of looking at risks and benefits. If you were to ask me personally, I'd sue for assault if forceps of any kind were brought within one mile of me. Nothing has the potential to upset me as much as a forceps delivery when it comes to childbirth, particularly when it is forced.