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?

[TurquoiseDress]

Very interesting thread, strong views & opinions being expressed.

Didn't realise at first that it was from a few years ago- still very relevant debate.

[PenguinsIsSleepDeprived]

Zombie thread!

[tstockmann]

A few details about forceps delivery that pregnancy books, midwives and antenatal teachers never tell you: faecal incontinence and pelvic organ prolapse straight after birth (which leads to major incontinence problems and sexual dysfunction as well as mobility issues).

forcepsthefollowonblog.wordpress.com/2014/10/28/what-i-wish-id-known-before-giving-birth/

[riskaverse]

wrong; forceps will only get used when the baby is through the ischial spines (low) and how often Keillands get used depends upon the Obstetric Unit they are being used in.

[Bibbo]

yes me for one

lots of luck spanner however it goes :)

[spannermary]

Well, I've just had my 36 week MW appt and they think the little man is breech anyway, so it could all be academic in my case!

Scan on Monday to find out.

It's still been a very interesting read - and the MW could be wrong...

It's certainly given me a lot to think about - and I know it's been useful to others too. :)

[PeaceAndHope]

Pastabee:

You make good points.

I'll quickly point out that it isn't just Keillands forceps deliveries that are performed in theatre. From my understanding, Neville barnes and other mid forceps deliveries(Elliot, Simpsons etc) are often also done in theatre. These things may vary from hospital to hospital, but I'm just putting it out there.


I was told by my doctor that once the diameter is 2.5 cm or more above the vulva, low forceps are used as a simple lift out procedure. I'm happy to be corrected about the exact diameter though.

[Pastabee]

Hi spannermary. I don't think anyone can tell you which is safest as i think it depends on the circumstances really. Forceps get put under one heading but there are many different types.

My baby became very distressed coupled with merconion in the waters and the obs and paediatrician wanted her born ASAP. They used forceps but I'd pushed her to the end anyway so it was just a small lift out with small episiotomy and small tear which have healed well. There wasn't a mark on DD. This was all done in the delivery room. If I had insisted on CS I would have been transferred to theatre and given an epidural which would have taken 20 mins or so and DD would have been pushed back up as she was low which I think carries a risk of cervical damage and would have further distressed DD.

The decision to delivery time with low forceps was less than 5 mins including local anaesthetic going in so in my circumstances better for me and better for DD who was quickly seen by the pead who got her breathing sorted etc.

Having said that I wouldn't have consented to high rotational forceps. As mentioned above if you are in theatre prepped for CS you may well feel its best to go for CS. It is well worth talking to your midwife about this though. I got worked up at thought of Keillands and midwife informed me at 36 week appointment that they are not used at my hospital and they always go for CS instead.

I've always felt consenting to low forceps when the baby is nearly out and a CS when it is still high up represents a sensible middle ground but that's just me.

In terms of my own experience I was grateful to have avoided an epidural. I had a bath 90 minutes after DD was born which was really nice and I could go to the loo on my own, change her nappy etc.

[PeaceAndHope]

Bibbo:

I think you make a very interesting point about women who have to recover from both an episiotomy/tear as well as a CS. I've known women who've consented to a trial of forceps hoping to be 'spared' a CS recovery only to end up having to recover from both due to a failed operative delivery.

It's very important to remember that forceps can and do fail, sometimes even when the doctor is confident they'll work. There a reason majority of the operative births are done in theatre with mum prepped for a CS as well.

I think for me this would be the red flag- if they were making preparations for a CS anyway and then attempting an operative delivery. The most often given justification for forceps is that it's faster as it takes longer to prep for a CS. But if you're being prepped for a CS anyway, then this whole argument of saving time falls apart. In fact, if the forceps fail and an EMCS is required, you've actually wasted double the time and will now have to recover from both.

[Bibbo]

I will say one positive thing about the CS recovery time though... I was in hosp for a week with DD, which sounds like hell I know, but the plus side was it meant I had an awful lot of early bfing support, which we both really needed help with!! and by the time we left hosp bfing was well established.

As my 1st LO it was also reassuring to have lots of support in learning to care for her, and I was able to do a lot of that as I was up and about after less than a day. Yes the stitches did hurt but I had my wonderful friend Mr Morphine to help out, but not so much that it zonked me - I felt able to care for DD at all times.

I was itching to get home by the end though, if only to get away from all those other newborns caterwauling all night long!! I would have been released earlier but DD had jaundice and was in the lightbox, otherwise we'd have been out a few days sooner.

Also I remember in the ward opposite me was another woman who'd had an em c/s after failed forceps - and my goodness she was suffering. the poor woman was butchered from the waist down, with a huge episiotomy as well as her cs scar. I felt so sorry for her and I was very relieved that I had made a fuss about not wanting an episiotomy and as a result had been spared the forceps!

I have a bicornuate uterus which apparently may be the reason why I had such trouble pushing her out :( am planning a VBAC this time round, all being well, but if there are difficulties again I will most definitely be going for another cs

[SleepyFergus]

I had a forceps delivery and it was absolutely fine. My DD had her hand up at her head (like she was saluting) and I'd been pushing for a while, but she wasnt for coming out! I was given an episiotomy and then they merely used the forceps to 'guide her out' apparently. No trauma to me or my DD. She had no marks whatsoever.

My worst fear is having a CS. If it came to it and it was an emergency, then so be it, but I'd rather avoid at all costs. I don't want major surgery and a long recovery time with a birth. After my DD, I was up and about relatively quickly.

[spannermary]

Thanks for your perspective, Mraw - interesting comments. Sorry to hear how you were treated the first time...I'm really hoping to avoid being induced, so I find it terrible to see that you were induced early for no real reason!

[Mrawmraw]

It's hard to tell, but I have heard too many horror stories about forceps I think I'd be refusing and going for a section at the moment of problems.

I think I'd rather have a non-intervention vaginal or else an elective c-section (equally).

I will never know though because I was induced for no real reason with my first at 38 weeks (have since read notes and had them 'explained' to me , apparently reason for induction was "young mother with social problems" ), which ended up in 'emergency c-section' due to not even dilating 1cm despite 3 rounds of the pessary thingys!

Second baby I went for elective C-section when given choice of trial of VBAC or elective c-section. Main deciding factor was I know I want a small family , not 3+ babies, and the c-section wasn't traumatic for me the first time and recovered very well both times. Also the consultant basically told me I'd have 12 hours to do VBAC, if I stalled for a certain length of time would be sectioned anyway, and I'd never been in labour before. Would have to have continuous monitoring, no pool etc , didn't appeal to me much than to try a moving-around birth would , but don't know if it's the same everywhere.

My MIL had forceps and blames them for her major prolapse.

[thefurryone]

I have never once said that CS isn't a good option for some people, why do you keep accusing me of this?

[Booboostoo]

For what it's worth I found it useful to look at studies and articles comparing birth options directly on Google Scholar. It's not that difficult to evaluate the data and come to a preliminary choice which can then be discussed with your doctor. The US and Chinese studies were particularly useful because of the large percentages of women chosing CS which allowed for statistically significant differentiations between the outcomes of ELCS and EMCS.

My main conclusion was that while an unproblematic VB was by far the preferable option, whether you got one or not is a matter of luck, so I preferred the control offered by ELCS.

[PeaceAndHope]

Thefurryone:

I can likewise allude that you are not interested in any opinion that states even a slight preference for a CS. It may not be the best option for you when things get difficult, but it maybe for someone else, given that every woman's expectations from the process are diverse.

Let me explain- My POV is that everyone is different. In exactly the same scenario, I may prefer a CS and you may prefer a different intervention. Why? Because we are both prepared to take different risks, given that our priorities are completely different.

I'm not shy in admitting that I am completely against the use of forceps. But this does not translate to mean that I advocate CS for every woman or that I don't accept that other women may be agreeable to the risks of a forceps delivery. I merely advocate full disclosure of risks (prior to the onset of labour) and a respect for individual preferences.

[thefurryone]

peaceandhope to be honest I don't think you're particularly interested in any opinion or experience that may suggest that CS is not always the best option when things get a bit complicated.

[PeaceAndHope]

LaVolcan:

I'm not pro CS, I'm pro-choice. I advocate patient choice and full consent and I support the right of a woman to refuse forceps in favour of a CS. I am simply against the real risks of any procedure being glossed over or women being bullied out of their birth preferences.

The study lists forceps as part of the top 4 factors causing severe perineal tears (which can lead to a further multitude of complications). I stated forceps as a major risk factor for third degree tears among others. Where exactly is the issue?

I'm not saying forceps bad, CS good. I'm only saying forceps bad. I don't pretend that a CS is a walk in the park and I'm far from advocating them for everybody, but I wouldn't advocate a forceps delivery to anyone. This is my opinion based on my risk-benefit analysis. I'm sure many people disagree, but I'm also sure that many people agree.

[PeaceAndHope]

Shagmund:

I am honestly no longer interested in your opinions regarding forceps v/s CS.

Anyway, I am not alluding to any conspiracy. I just find it unethical that NHS and RCOG don't find it necessary to disclose the real risks of a forceps delivery and limit the disclosure to 'mild bruising' when we all know the risks go way beyond that. I have no way of knowing what their reasons are for not listing all the potential risks but I'd love to find out.

I am not saying that doctors are deliberately harming patients, but I do feel that they sometimes encourage forceps in place of CS and this decision is often influenced by cost among other things.

My OB has often performed forceps deliveries in the NHS hospital she practices in, but never in her private practice. She clearly told me she would never encourage me to consent to them. I don't know what this anecdote means in the larger scheme of things, but it's very telling for me.

I don't think doctors are an unethical, nasty bunch contrary to what you have assumed, but I am not naive enough to assume that their decisions are solely based on patient welfare and choice and are unaffected by costs, policies, time and personal bias. That just doesnt happen in the real world. Which is why I prefer to do my own research and form my own opinion instead of blinding trusting an HCP. Their guidance is welcome and respected, but since I have to live with the outcome of either mode of delivery it makes more sense for the final decision to be my own. I hope you finally get the gist of what I'm saying.

[LaVolcan]

PeaceAndHope
You seem to be very pro Caesarean and give me the impression that it?s your preferred manner of birth.

I haven?t had time to check out all your links, so I just picked one:

Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair

Towards the end of the article it says: Attention should be directed towards preventive obstetric practice and surgical techniques of repair.

(It didn?t say what it regarded as preventive obstetric practice ? it could have been earlier CS or it could have been better care in the first stage reducing the risk of complications necessitating intervention.)

As you point out forceps is one of the major risk factors for third degree tears but it's only one.
It concludes:
Forceps delivery, first vaginal delivery, a large baby (>4 kg), and persistent fetal occipitoposterior position are the main risk factors.

So it?s not a simple ?forceps bad: CS good? position.

[shagmundfreud]

"Anyway, you support forceps deliveries and you seem to have a fear of CS"

Ok - here you go:

I think in some situations forceps are safer than an emergency c/s.

I think c/s is sometimes the only safe way to birth a baby, and that sometimes this is also true of forceps.

There is serious morbidity associated with both forceps and c/s, though this is rare.


I have no 'fear' of c/s. I am quite happy to admit that like most routine procedures, it's generally a very safe operation, though the balance of risks and benefits will change throughout a mother's reproductive life.

OK?

Would like to add, I'm very saddened by your insistence that doctors in the UK are regularly, knowingly and deliberately inflicting unnecessary damage on mothers and babies by doing forceps births when (at least as far as you are concerned) there is CLEAR evidence that c/s is safer. To save the NHS money.

Also that you think the RCOG and the RCM are involved in some sort of conspiracy to cover this state of affairs up by producing incomplete and partial information for patients.

[Bibbo]

UmaT :(

how awful for you and dd1

i must say i am shocked that this isn't considered medical negligence

to have such lasting damage for you and your baby, which surely could have been avoided with a cs?

am :( and on your behalf

[PeaceAndHope]

Shagmundfreud:

You can rely solely on the RCOG and nhs website and disregard all other research if you so wish. I personally don't wish to fully trust a website that believes in selective disclosure. The only risks of forceps they mention are mild bruising and anal lacerations, which hardly inspires trust in their ethics.

Contrary to your claim, I posted not one but several research papers analysing the outcomes of forceps deliveries in not just UK but other countries as well. If you read only one of them, I can't be held responsible for your selective reading.

Given that you have come up with an empty piece of research to support your stand (god knows what that even is), it's funny that you accuse me of trawling the Internet.

Anyway, I no longer wish to engage with you. You have an opinion (I'm stil, not sure what that is) and you are welcome to it.

OP, my apologies for the unpleasantness in your thread.

[PeaceAndHope]

Shagmund:

You can post one study that states "not enough evidence" but I've posted several that are sufficient evidence to illustrate the many risks of forceps. I honestly don't understand what you are gaining by supporting a medieval practice. I don't even know what you're trying to prove. You seem to be arguing aimlessly without any point whatsoever to make.

There will be the odd forceps delivery in any country, but remember that all countries have rural areas where there isn't enough infrastructure for CS. The rate in USA is 0.8% and in Canada it's 4%. The rates in China are almost zero. The rates in NZ, Australia and India vary greatly by area. However the major hospitals in these countries do not support forceps over CS.
You are mistaken to assume that these countries support random episiotomies and such like. It depends entirely on the hospital and individual HCP.

Anyway, you support forceps deliveries and you seem to have a fear of CS. I think we all understand that by now, there is no point in going over this repeatedly. You are no longer offering anything constructive, you're simply hijacking the thread to suit some sort of agenda.

[shagmundfreud]

"your insistence that CS cause higher morbidity isn't supported by research."

What - based on that one study from the USA?



Yes - you are right that there can be very poor outcomes for babies associated with assisted delivery.

In any case - I respect your need to trawl the internet in search of studies supporting your thesis that the use of forceps is unsupportable.

I'm afraid though for myself I prefer to rely on evidence from RCT's which form the basis for current obstetric practice in the UK, as I think the outcomes for birth at a population level here are generally pretty acceptable (though admit they would be VASTLY better if we doubled the number of midwives and birth centres, and if British mothers weren't generally so much older and fatter than women on the continent )

Now - I'll leave you to it Peace. I do wish you'd apologise for your unkind personal comment further back on the thread though. I appreciate this is a very emotive subject for you, but I think it's disrespectful to bring character assassination into a thread where there has largely been polite debate about a subject of very great interest and importance.