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 know too many women whose pelvic floors have been damaged by forceps deliveries. In retrospect, some of them say they'd have opted for c-section, had they known - but nobody does know, and that's the problem.

With DS1, who was induced, I eventually had venteuse. The obs wanted to go for forceps because he said they were more 'certain' (I think he meant, on first go), but with the knowledge of my SIL's traumatic birth fresh in my mind (which involved forceps and pelvic floor damage) I insisted on venteuse first. DS1 popped out on the first suck, and I think forceps were completely unindicated.

I honestly think if I did it a third time (DS2 was a straightforward vaginal birth) and ran into complications where forceps were suggested, I'd insist (or get someone to insist for me) to go straight to EMCS.

What upsets me is not really the fact that forceps are used, but the fact that majority of the women here are stating that they weren't given a choice.

I find that galling.

i'm in ireland where kielland's forceps are not used and frankly, i'm shocked that they are in the UK. i would definitely rather a CS than them.

i had neville barnes forceps to get DS out and while it's not an experience i enjoyed, i don't think it was as bad as you'd think. doc got DS's head out in one push and removed the forceps and then 2 more pushes and he was out. i had an episiotomy (one running stitch) and defo bruising for a couple of days and serious lack of pelvic floor control for a few weeks but considering DS was 11lbs (5.01kgs) i may have suffered the same issues even without the forceps.

i never, ever did pelvic floor exercises and never had a problem until i got pregnant again. am now 25 weeks and defo have to make a dash to the loo at times but i think if i had done my exercises i would be ok.

i'm in 2 minds about what to do this time re consenting to forceps as am terrified baby will be even bigger and may do more damage so unless he/she shoots out i'm wary of intervention. having done some research the baby's "station" in the pelvis has an impact on the success of forceps so i may go in armed with info about that and if forceps are mentioned, ask re the station and make a decision from there. might be something you could do too?

Having had two caesareans, both of which had no impact upon my baby I would be inclined to say caesarean. However I too read quite a lot before having my babies and I found that the level of risk to my baby in terms of nicks and pressure damage were greater with forceps than with a caesarean.

There is a really useful book 'caesarean birth: a positive approach to preparation and recovery' see www.csections.org which has an up-to-date analysis of all the latest research on risks and benefits of vaginal versus caesarean birth. It talks specifically about forcep damage.

The only thing I would say is that you shouldn't leave it as late as possible during labour to make your decision because once your baby has passed quite a way down the birth canal she will have to be pushed back up if you then decide you want/need a caesarean and it may well be that you will have progressed so far that they wont give you that option and then it will be forceps regardless.

Not sure but I had both, baby was wedged in so tight that he was dragged out by forceps during c-section. And we are both fine though at first he couldn't lie with his head back, only on the side.

So now I need to do more research! What exactly are 'stations'?

I can definitely see where people are coming from regarding making decisions earlier rather than later - I'll be discussing all of this with DH too, so he's in no doubt about my opinions before the big day!

Also - PPH? No idea what it is but it sounds painful.

PPH is post partum haemorrhage - a bleed of over 500ml.

Another one here with Keilands forceps delivery -:(
DS's head was bruised and he had a lump on his neck from a ruptured muscle. I bled massively and took ages to recover, pelvic floor is OK but the birth trauma prevented me from enjoying my DS as much as I would have done otherwise.. I was so exhaused and weak and worried for him, with his bruises and constant vomiting!

I totally agree with those who say an elective cesarean is much better than forceps delivery, for both mother and baby

No need to research further - your answer is right here

Good luck!

"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."

But most women who have augmentation go on to have a normal delivery.

And in fact a very large proportion of cases where there is foetal distress end with the vaginal birth of a healthy baby.

I'm amazed at your confidence at encouraging someone to insist on having major surgery regardless of clinical opinion at the time. You do realise that operations sometimes go wrong too? Sometimes catastrophically? And that you're more likely to die or lose your uterus/have a terrible bleed or severe infection after an emergency c/s than you are after a vaginal birth?

Christ - I wouldn't advise anyone to do anything other than listen to the doctors and then make up their own mind. As someone who's not a medic I'd never want to advise someone to accept or refuse any sort of major surgical intervention.

I think the key thing is to make informed decisions rather than simply follow the advise you are being given (be that advice from professionals or well meaning friends). Ask questions and read more. It is unfortunately the case that personal agendas colour the amount and quality of information women may be given, particularly when they are in labour,( time constraints being what they are it is not always possible to give you all the relevant facts). Also a woman's ability to hear everything when in the middle of contractions is also coloured by circumstances.

Informed decisions can only really be made if you prepare in advance and have a good idea of the questions you would want to ask and what the risks are with the various options you might be presented with.

'Caesarean Birth: A posiitive approach to preparation and recovery' (available on Amazon) spends a lot of time talking about this from a mothers perspective.

Shagmunfreud:

You keep talking about informed consent all the time and yet every one of your posts has a barely concealed contempt for CS.

Why can't we advise OP on what procedures to accept or refuse based on our experiences, even if we aren't medics?
You would be naive to assume HCP's always give ethical advice. An NHS doctor's advice may be based less on an individual patient's welfare and more on hospital policy and cutting costs. A private physician may be more concerned with the best way to make maximum money or avoid litigation.
It is certainly worth it to listen to what HCPs say, but individual research and the experiences of other women can be very helpful as well.

Do you realise that most of the women here have researched their options thoroughly? Did it strike you that some of us are OK with the risks of infection and longer recovery as long as we can avoid the risks associated with an operative vaginal birth?
The risk of dying in childbirth is extremely low no matter what the mode of delivery, so I don't see why we have to scare women with it anyway.
Secondly, a CS does not always increase the risk of PPH. In fact, recent research shows that a planned CS may actually reduce the risk of developing a PPH.
Since most operative births include either an episiotomy or severe tearing, an infection is quite likely in that instance as well. I know someone who developed a terrible staph infection at the site of her stitches after a forceps delivery. There happens to be someone on this forum who is left with a permanent colostomy following an operative birth, so I honestly don't see what you are trying to defend.

Sorry to jump in here but

Why can't we advise OP on what procedures to accept or refuse based on our experiences, even if we aren't medics?

Err because we're not medics surely as you said yourself in your earlier post most people posting here will have a view that is skewed by their own personal experience. All we can do is talk about our own experiences, point people in the direction of the research and give advice on the best questions to ask and how to brief birthing partners fully. It is frankly reckless to TELL anyone what they should accept or refuse during labour. We don't know that person's full medical history and we have no way of knowing what would be the right option for the particular circumstances that any poster may find themselves in during labour.

If I'd followed the advice to request a CS at the first sign of trouble or because I didn't want to be induced, I could have ended up having totally unnecessary abdominal surgery. I would now be facing very different childbirth options for this pregnancy, and the relief that I can just approach my due date with a lets just see how it goes attitude is enormous.

It really isn't a case of assisted delivery bad, CS good.

thefurryone:

I don't think you really understood what I'm trying to say. I never once implied that we should TELL the OP what to do. We are all giving advice based on our extensive research and individual experiences and elaborating upon what we would personally do if faced with a choice between a CS and forceps delivery.

For instance, if somebody asks me for feedback on a drug which gave me nasty side effects, I would feel obliged to warn that person about my experience and that person would be smart to reconsider his/her decision to take that drug. At the end of the day however, it would be his/her choice as we are all free to choose our own risks.

The whole purpose of this website is to ask other women for advice and opinions. If it were only the opinions of an HCP that counted, we would all have been on askthedoctor.com, not mumsnet. As I said, HCP's don't always offer the most ethical or unbiased advice themselves, which is why asking others who have been through the same thing is so important.

You may not want to go for a CS at the first sign of trouble, but you must realise that other people may prefer that approach. A lot of women are happy to opt for a surgery that may seem unnecessary to you, but to them it is a better option than the possibility of dystocia or an assisted birth. It's very subjective.You should also realise that plenty of women don't really mind having to go for a repeat CS in subsequent pregnancies particularly if they plan on a small family. You find relief in a "lets just see how it goes attitude", whereas others may find the uncertainty unsettling and actually prefer a planned CS.

"yet every one of your posts has a barely concealed contempt for CS"

Concealed or not concealed?

I have no contempt for c/s. I'm profounding grateful that this procedure exists, as it has saved the lives of women and babies that I know.

"The risk of dying in childbirth is extremely low no matter what the mode of delivery, so I don't see why we have to scare women with it anyway."

Yes - it is low. Thank goodness. Are you saying it's so low it simply shouldn't be mentioned by medics seeking consent? Or generally in discussion of the topic of birth?

"Secondly, a CS does not always increase the risk of PPH"

An emergency c/s increases the risk of PPH above any other mode of birth. And it was an emergency c/s that was the subject under discussion, no? (I was responding to this comment:
"If I were advising a friend I'd say if you go into labour naturally and there are complications, insist on a CS immediately" posted by StillSquiffy, which I did make clear in my post.)

"Since most operative births include either an episiotomy or severe tearing"

Most forceps births involve an episiotomy.

Not necessarily so of ventouse.

Do you have figures for the rate of severe tears? Involved in operative deliveries? Your comment suggests you do. My understanding is that most women undergoing ventouse or forceps deliveries emerge with a second degree tear or an episiotomy, which is repaired by a midwife and heals without difficulty. The RCOG greentop guidance on this states that between 4 and 8 women in a 100 who have ventouse will have a 3rd (or 4th) degree tear. The figures for forceps are 8 - 12 in a 100. I'm not aware of what proportion of these will cause further problems to the mother. Are you?

"Since most operative births include either an episiotomy or severe tearing, an infection is quite likely in that instance as well"

I'm not aware of the figures on this. Do you have them to hand?

"There happens to be someone on this forum who is left with a permanent colostomy following an operative birth, so I honestly don't see what you are trying to defend."

Well, we can trade anecdotes endlessly about friends of ours. I know someone left with a colostomy following an c/s where her bowel was nicked by the surgeon. Also someone who nearly died after her placenta grew through the scar of her previous c/s and attached itself to her bowel.

All types of surgery and assisted birth have dangers. I'm not denying this.

I just think it's dishonest to try to argue that there are any easy answers to any of this or any absolutes.

At a certain point I think you have to trust that the medical professionals want what is best, and safest, for you and your baby.

Thanks for all the opinions! I can see it's quite a heated issue.

As for advising me about which course to take, I am very interested to hear about all of your experiences, opinions, stats and figures. I've completed a decent amount of Masters Level research in my time, so like to think I can assess and reach the conclusion that works for me: and that means looking at all sides!

So keep them coming...whatever opinion they offer. I really am most grateful, and it gives me a lot to think about.

shagmund:

Firstly, you need to reconsider your sources. Recent NICE findings have shown that women are no more likely to develop infection or heamorrheage after a CS as compared to a VB.

Here is the synopsis of the research as given on mumsnet itself-

www.mumsnet.com/pregnancy/labour-and-birth/caesarean-section

Secondly, if you refer to the links I had provided earlier you will see that the highest risk factor for third and fourth degree tears, POP and trauma to the baby is actually a forceps delivery and some people are just not prepared to take that risk. There are statistics quoted for various demographics in the links I have quoted earlier, so feel free to have a look.

No, I cannot say which one of these women will end up with complications following a forceps delivery. But then again, you are in no position to say which woman will end up with a hysterectomy following a CS. You cannot give anybody guarantees about the outcome of an intervention which is why they need to look at the worst case scenarios of both options and decide which risks they prefer.

You clearly seem to be opposed to CS completely and are resorting to supporting instruments which are clearly risky and have been abandoned in several countries. The rate of forceps deliveries in USA and Canada is below 1% now. Even in Asian countries such as India, China, Singapore, Malaysia and some others forceps are gradually being abandoned in favour of CS. I am sure they have a reason behind this trend and it isn't just about random preference.

jeee:

Of course we must trust medical professionals. But I will say this again- they are not god and their advice is not always free from bias and agendas. Even if they are well-meaning, they may often lack the experience and expertise to make the right decisions. That is why it is so important to be informed and to learn from the experiences of others.

PeaceandHope I do realise that other women have different views on whether a CS is a good option for them than I do. Do you? Because you seem most affronted that I have presented an alternative view on why it might be some women might find it an assisted birth preferable in order to avoid a CS or are we not allowed to talk about how there are also downsides to that procedure?

I had Wrigleys forceps (the smallest ones) and no problem. Baby came out without a mark on him, lovely clear skin, I had a spinal block (in case of emcs) so didn't feel a thing and it was all very straight-forward, including my recovery.

I am very glad I didn't go straight for the cs option. I was up and about very quickly, same as with any other natural birth, unlike a cs which is a major procedure and can really affect those early weeks with your newborn.

I had forceps in the c/s, so they didn't hurt me but DD2 had a horrific black eye and bruising, red eyeball etc. They saved her life though, so I can't say I would want anything different. However, I certainly wasn't asked, just told what they were doing as they did it.

"Firstly, you need to reconsider your sources. Recent NICE findings have shown that women are no more likely to develop infection or heamorrheage after a CS as compared to a VB"

Planned c/s are 'as safe' as planned v/b's mainly because 12% of planned v/b's end up being emergency c/s. The bulk of SERIOUS morbidity relating to v/b is attached to v/b's ending in unplanned c/s.

Obviously the balance of risks and benefits when it comes to planning a vb over planning elcs will partly depend on the individual mother's risk of unplanned c/s, which will be massively lower for some mothers than for others, as are the risks of surgery.

"Secondly, if you refer to the links I had provided earlier you will see that the highest risk factor for third and fourth degree tears, POP and trauma to the baby is actually a forceps delivery and some people are just not prepared to take that risk. "

Yes, I agree. I appreciate some women would prefer the risks associated with having abdominal surgery with those associated with a planned v/b. I'm not arguing that women don't have a right to have a preference!

I'm not sure what you're arguing for. C/S on demand in the NHS?

"But then again, you are in no position to say which woman will end up with a hysterectomy following a CS."

No. I agree. I don't believe I've attempted to do that on this thread.

"You cannot give anybody guarantees about the outcome of an intervention which is why they need to look at the worst case scenarios of both options and decide which risks they prefer."

Yup - not saying anyone can have any guarantees either.

"You clearly seem to be opposed to CS completely"

Ummm, how? It's a life saving operation for some women and babies. Why would anyone be against that?

"and are resorting to supporting instruments which are clearly risky and have been abandoned in several countries"

If you're arguing that they should be banned, well you're entitled to an opinion on this.

But as someone who's had a forceps delivery, I'm exceptionally glad they haven't been banned! And I could find you dozens and dozens and dozens of women who say the same.

I have to say, I'm always a bit chary of reading too much in to the practices of other countries where doctors are known to practice defensive medicine, as they do in many countries with private obstetric led systems.

thefurryone:

If you prefer a forceps delivery despite it's risks, that is certainly your decision to make and you have every right to make that choice.
I don't really care if you talk about the risks of a CS, but your posts seemed to imply that it was ridiculous for women to have the "better safe than sorry" approach and go for a CS at the first sign of trouble. I was merely pointing out that a lot of women are happy to opt for a surgery that you deem unnecessary in an effort to eliminate the possibility of a forceps birth, the risks of which may be unacceptable to them.
If were to ever attempt a natural birth again, I would also want to go for a CS at the first sign of trouble. I am aware that this may result in a surgery that could possibly be "unnecessary", but that is a chance I am happy to take.

PuffPants:

I have had a planned CS and I was discharged after 3 days and shopping at Waitrose the next day, whereas my sister who had her baby 3 months before me(with the assistance of a ventouse) was still sitting on a tube. There is no "rule" when it comes to recovery from what I have noticed. It really is luck of the draw.

toddlermama:

I think the reason they didn't ask you before using the forceps during the CS is because it would not have affected your body directly as it would have during a VB.
Using forceps during a VB without the mother's informed consent amounts to assault.

"If you prefer a forceps delivery despite it's risks, that is certainly your decision to make and you have every right to make that choice. "

How can a mother make a truly informed choice about the risks of forceps when for every individual the risks will be different - depending on: the size of the mother, the shape of her pelvis, and the position and size of the baby?

You seem to think these things are absolute, and can be explained coherently in an emergency situation to a mother who may have been in labour for many, many hours. I would beg to differ.

Honestly Peace - nothing is that simple. For some women an emergency c/s may absolutely be the best option when birth becomes complicated. But for others it actually may be more dangerous than delivering the baby vaginally with forceps.

In the end it comes down to what happens to that mother and that baby during that birth.

I had forceps and a huge pph and transfusion, however I was still unbelievably grateful to have avoided a c section like my first birth. I personally don't "get" people opting for a c section against medical advice.

After the birth I talked to my obstetrician who said it would still be safe for me to have another baby. I asked if it would be better to be c section and she undoubtedly said it would be far better not to have a planned c section as there was a higher risk of complications and the floppy womb leading to pph was actually more likely with a c section. They wanted me to go for another natural birth but in consultant unit etc. She was of the impression that many people asking for c sections were unaware of the dangers and she herself preferred only to do them when absolutely necessary.

Obstetricians obviously must disagree on these things!

Each birth is also very different - I would be tempted to listen to the advice of trained medical staff on the day over and above annecdotes from the internet!

shagmunfeud:

I am arguing for nothing. It seems to me that you however are arguing against CS and obstetric-led systems.

Didn't you end up with incontinence or something following your forceps delivery or was that someone else? Anyway, two people very close to me have lost their babies due to forceps so I am not glad that they are still used, but as you said we are entitled to our opinions.

"The bulk of serious morbidity following VB is related to EMCS"

This is something you have pulled out of your biased hat. There is absolutely no research that states anything remotely related to what you have stated.
This statement seems to imply that VB can only cause serious damage if it ends in a CS which is laughable. VBs ending in forceps and/or ventouse deliveries can just as easily cause serious morbidity, and recent research supports this theory.

"I have to say, I'm always a bit chary of reading too much in to the practices of other countries where doctors are known to practice defensive medicine, as they do in many countries with private obstetric led systems."

Erm, no. Not all the countries I listed have private healthcare and not all the OBs in these countries practice defensive medicine.
Secondly, don't discount the reasons behind the practice of defensive medicine. In the USA, there has been no record of a doctor being sued for performing a CS. However, the rates of birth injuries with forceps were so high and the complications so severe, that plenty of doctors were sued for malpractice for using forceps when CS were an alternative. Courts aren't like the Daily Mail- they base their decision on facts;)

If you could find me dozens of women who are happy to have had forceps deliveries, I could find you dozens who were miserable with the outcome. You cannot give anyone an assurance which side she will be on, so it's best to leave people to make their own choices instead of veiled attempts at attacking a procedure you have a bias against.