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?

Can I just jump in and say, fascinating thread - has given me lots to think about in the run up to DD2's birth in June

When it comes to childbirth I really feel it's important to do the research, not just on what HCPs say but also women who've been there - neither source is infallible of course, but for me, it is totally invaluable to hear other women's experiences. It presents you with a whole set of perspectives that you just wouldn't get from an HCP.

So I'm really glad there are threads like this where you can hear real experiences (even if it does end up descending into NICE-guidelines-at-dawn!)

shagmunfreud:

I am not proposing that a detailed risk-benefit analysis be done with a woman in active labour. That just isn't possible. I am proposing that women should make an effort to research the possibilities well in advance so that they know what they will consent to and what they prefer to avoid. I am also of the opinion that women be given a more detailed and less biased set of risks associated with each intervention during their ante-natal appointments. Surely that makes sense?
In labour, if a woman refuses a procedure, her choice must be respected even it goes against what the HCP believes is correct. You'd be naive to believe that OBs make decisions that aren't influenced by things like cost, time, and personal bias.
My nieghbour is a medical student and he has confessed to me that his senior recommended a forceps delivery on a woman who would have been better off with a CS so that he could "teach his students how to use forceps".
The sad fact is that there are people like this in the medical field and none of us have any way of knowing if the person treating us is one of them. Given these harsh realities, exercising a bit of caution and having preferences based on research is certainly a good idea. I fail to see why you are so against people having firm preferences about how their birth should go.

You argue that nobody can make a truly informed choice about forceps. Well, nobody can make a truly informed choice about anything for that matter. So should we just fail to look for advise and information and leave everything to chance? I don't even know what you are trying to prove here.

The effect of any intervention will certainly be different on different women, but the fact remains that there is a fixed set of risks associated with each procedure which can affect anyone. Making decisions based on those risks alone is hardly unreasonable.

If I had to hazard a guess I'd say you were badly affected by your forceps birth contrary to what you claim. Your attempt now is to convince yourself and others, that a CS is a terrible option and you would have been worse off after one. I think you are using the wrong approach to seek validation.

Peace and Hope - I think your last comment to Shagmund was uncalled for. None of what she has written gives me the impression she thinks CS is a terrible option.
You obviously have strong opinions on this issue. I agree with you that being informed is the best way to make a decision. But without all the relevant information at your fingertips, literally in these cases, it's very difficult to make the decision in advance. In an extreme emergency eg non recovering fetal heart rate or APH I would say "do it" in others I would say "just do a CS" rather than try forceps. Depends on so much information regarding position, station, flexion that the examiner can feel and you as the woman can't. Which is why women should educate themselves AND consider the experience of the doctor and MW's.

Bibbo I couldn't agree more! It's really helping me consider what may be right for me. I find reflection of this type invaluable.

...also chuckling at the NICE-guidelines-at-dawn comment. :)

Peaceandhope I never said it was ridiculous for a women to opt for a CS at the first sign of trouble. I just think advising a woman that this would be the best course of action to take should anything go a little off course during labour to be completely misguided. Childbirth just isn't that black and white, and the risks accompanying each intervention will vary depending on the exact circumstances of delivery.

Really the only advice it is ever appropriate to give a women about to give birth is keep an open mind, do a bit of research and brief your birthing partner on the questionst that they need to ask.

I had an elcs 4 weeks ago as I did not believe I was a good candidate for vbac. As it transpires my son was very much stuck inside me (39+1) and had to be wrestled out manually by two surgeons. He was unable to move up or down, had I laboured I feel it would've been disastrous, and, had they gone for the forceps option I'd have (imo) been ripped to shreds. CS every single time thank you. And please, please, please stop perpetuating the myth that a c-section leaves you bed-bound and useless for 6 weeks, it's very much on a case-per-case basis. I'd like to ride my horse very shortly - I can guarantee if they'd gone at me with forceps that would not be something I'd contemplate right now.

"I think your last comment to Shagmund was uncalled for. None of what she has written gives me the impression she thinks CS is a terrible option"

I think there's a name for this sort of argument tactic - 'poisoning the well' or something. Keep ascribing false opinions to someone, and then arguing against them. Really - there's no need for it and it spoils a thread.

"This statement seems to imply that VB can only cause serious damage if it ends in a CS which is laughable"

I have acknowledged Peace, that a percentage of forceps and ventouse end with the mother experiencing serious perineal damage. I was thinking more along the lines of hysterectomy, death, thrombo-embolisms - all more common with c/s. As is a mother ending up needing treatment in an ICU. It's that I was thinking of.

"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. "

No. And the US has one of the highest maternal death rates in the developed world. And one of the highest c/s rates.

"You cannot give anyone an assurance which side she will be on, so it's best to leave people to make their own choices"

But YOU seem to be the making a case for the banning of forceps! It's you who appears to be arguing for the restriction of maternal choice, not me!

"I am proposing that women should make an effort to research the possibilities well in advance so that they know what they will consent to"

And I would argue that it's almost impossible to do this in a truly meaningful way prior to delivery, because the risks associated with the use of forceps vary so significantly depending on the unique events of the birth. For some women forceps will cause significantly less harm than a c/s. For some more. But you can't know until it happens.

"but the fact remains that there is a fixed set of risks associated with each procedure"

Well this simply isn't true! The risks associated with mid cavity forceps delivery for a woman with a BMI of 36 will be different from the risks for a slender woman whose baby is lower down in the birth canal and needs less rotation. There are many, many variables which impact on the safety of surgical and assisted delivery.

By the way - I do wish you'd stop lumping ventouse and forceps in together as though they're one and the same thing. They're not!

"If I had to hazard a guess I'd say you were badly affected by your forceps birth contrary to what you claim. Your attempt now is to convince yourself and others, that a CS is a terrible option and you would have been worse off after one."

That's a bit uncalled for isn't it? I'm quite happy to admit that my forceps delivery did a fair degree of perineal damage. In my case it was complicated by the fact that my first baby was 9 and a half pounds. Luckily it hasn't affected my quality of life since in a way which makes me carry serious regrets about it. What reconciled me to it most of all was the fact that I went on to have two more babies, the second of which was a homebirth, which was an amazing, wonderful experience that I wouldn't have missed out on for all the world. I probably wouldn't have gone for a VBAC at home had I had a first c/s because I also had gestational diabetes and was carrying a very large baby (11lbs). I probably would have ended up with a repeat c/s, and then who knows if I would have even gone on to have a third pregnancy after that.

Besides which - I've said nothing to support your assertion that I believe c/s is 'terrible'. So maybe you could stop repeating this accusation.

trafficwarden:

My comment to shagmund was based on her attitude in numerous threads, not just this one. Despite her insistence to the contrary, she never loses an opportunity to point out exaggerated risks of a CS, most of which were true years ago and don't even apply any more ( as I pointed out in an earlier post).

I accept what you are saying that it is impossible to predict which way things will go. I do feel however, that there isn't anything wrong with having strong preferences. There are obstetric practices in various parts of the world which don't use forceps at all and most of them manage to deal perfectly well with emergencies with the assistance of either ventouse or CS. If they can manage it, I expect my HCP to manage it as well. This is just me however,I'm sure other people feel differently. I would have to be in extreme pain and under a lot of stress and pressure to consent to forceps. A situation I pray I never find myself in.

I had forceps and episiotomy and it was OK - only small mark on DD that disappeared overnight and bit of pain sittting for a few days after. Pelvic floor has recovered pretty much (although don't know if i'll ever be able to dance to footloose again).

I kept expecting to have an emcs while in labour but as DD was never distressed, it didn't happen. Was quite relieved to have avoided it in the end but can't say one is better than the other.

"she never loses an opportunity to point out exaggerated risks of a CS"

Where have I 'exaggerated' the risks of c/s? Seriously? Please give an example.

I get my information about c/s - planned and unplanned - from current RCOG greentop guidelines.

I am glad I had a forceps. DS got seriously distressed due to the cord being round his neck a couple of times. They were about to take me to theatre but found I was fully dilated and they used forceps to get him out pronto. Meant it took 5 minutes to get him out rather than the extra time to get to theatre. Doctor said it was much better to get him out as quickly as they could as in that situation every minute counted.
I had an episiotomy that healed fine. DS had some bruising but I count my lucky stars it could've been so much worse.

shagmundfeud:

Firstly, you state that the only type of morbidity that a forceps birth can cause is perineal. This is untrue. It has the potential to cause serious heamorrheage, infection and the need for further surgery. (read the links I have posted earlier) It also increases the risk of uterine prolapse, anal sphincter injuries, obstetric fistulas and various other complications which require major surgery to correct. A mother who develops a staph infection after a forceps birth (which is called an "operative birth" btw) or loses a lot of blood can end up in the ICU as well, so please don't imply that only CS mums end up in ICUs.
This may not be something you are aware of, but forceps can cause uterine rupture or lacerations and the need for a hysterectomy as well, so this isn't a risk with only CS. The important thing is the possibility of needing a hysterectomy as a result of either procedure is very, very small.

Your point about the US having a high maternal mortality rate and high CS rate is moot. China, Canada, Italy and Germany have very high CS rates as well and the lowest maternal mortality rates(other than of course the Scadanavian countries). You should look up the latest research which looks into the real reasons behind the high maternal mortality rates in USA. They don't have much to do with CS, and a lot to do with immigrant population, complications and neglect during pregnancy as well as lifestyle.

Thank you for telling me about the variations of a surgical birth, but there was really no need. I am well aware that different women will be in different risk classes. There is still no denying the fact that there is a general set of risks which are applicable to anyone undergoing a surgical birth. The level may be different, but the risks don't suddenly change or disappear.
The risks to the baby with a forceps birth are what they are- spinal cord injuries, shoulder dystocia, cerebral palsy, facial nerve palsy, brachial plexus injuries, intracranial heamorrheage, brain damage and in rare cases paralysis or death. Of course these would be higher or lower with certain kind of forceps and will be influenced by other factors, but they will still be applicable at some level. Simply on the basis of the above list a woman can decide against forceps and she would be justified in that decision.
You keep arguing that there is no way of obtaining informed consent and your arguments are making no sense. Obviously nobody can be given a guarantee as to how their birth will progress but it seems ridiculous to imply that because of that unpredictability informing women of the risks of a procedure has no benefit. I notice you are quick to broadcast the risks of a CS- doesn't your theory apply here? Why inform women about the risks of a CS either then if it is all so pointless?
You can know nothing until it happens. That is however, a rather strange reason to abandon the concept of risk analysis and informed consent. There is a general set of pros and cons with each procedure and women are justified in basing their decisions on that.
I don't agree with the concept of not informing women of the real risks involved with a procedure.

You clearly desired a large family and are therefore happy to have avoided a CS. For women like who don't plan on more than one or two children, a CS is far from the end of the world.
I'm glad that forceps did not affect your quality of life, but perhaps you need to stop and think about the multitude of women(many on this forum) who were not as lucky.
You chose to deliver an 11 pound baby vaginally and I wouldn't even have considered it. The risks of shoulder dystocia, erb's palsy and pelvic floor dysfunction would not have been risks I would have taken. I am not judging your choice, I am merely trying to show you that different women want different things from the birthing experience and they view risks differently.

Shagmund:

You have implied that ICU admissions, infections and severe blood loss are risks associated only with CS. I have posted the recent NICE research and guidelines which clearly states this isn't true. Women are no longer more likely to have infections or heamorrheage after a CS when compared to a VB and ICU admissions do happen after VBs as well. You haven't mentioned the risks associated with forceps even once, whereas you insist on painting a drastic picture of CS. By all means talk about the risks of a CS, but don't pretend that forceps are safer or easier- that simply hasn't been established nor is it supported by any form of research.

I lurk here often and I really wanted to share my experience.I had a forceps birth DD1 and it was the worst experience of my life.According to my notes they used Neville Barn forceps on me.Five years on I'm still left with incontinence and prolapse. I had a third degree tear which resulted in double incontinence, rectal prolapse and extreme pain during intercourse. I couldn't sit in certain positions, poo without screaming or have sex for at least 7 months after she was born. DD1 still has a very visible mark on her cheek and poor thing couldn't move her left shoulder or arm until last year. Full recovery is impossible for either of us. This experience had severely impacted my marriage and my ability to bond with my daughetr.I wouldn't wish this on my worst enemy and I always tell my friends to think very carefully about consenting to forceps. The midwife who saw me at my post natal appointment said that none of the consultants themselves would ever opt for a forceps delivery because they know exactly what can happen.My next pregnancy was accidental and I was miserable at the prospect of enduring a complicated delivery again. ThankfullyI managed to get a scheduled cesarian and it was bliss! I recovered within two weeks and DD2 was born healthy and she breastfed without any trouble at all. I bonded instantly with DD2 whereas with DD1 I didn't even want to believe she was mine.

"You haven't mentioned the risks associated with forceps even once"

I think you'll find I have. But I'll repeat it below if it helps.

I also didn't say there is 'no benefit' from telling women what is known about the comparative risks of different types of procedures.

"For women like who don't plan on more than one or two children, a CS is far from the end of the world"

No - of course. I have never implied that it was or is!

"You have implied that ICU admissions, infections and severe blood loss are risks associated only with CS"

Well, apologies if I've given this impression. I'm aware that forceps and ventouse are occasionally associated with gynaecological damage which is life changing (as - sometimes - are c/s).

Anyway, do you have access for outcomes for the things you mention for assisted delivery from the UK? Particularly those for outcomes such as admission to ICU and hysterectomy?

The figures for c/s from the greentop guidelines are:

• emergency hysterectomy, seven to eight women in every 1000
• admission to intensive care unit: nine women in every 1000
• thromboembolic disease, 4?16 women in every 10 000
• death, approximately one woman in every 12 000
• increased risk of uterine rupture during subsequent pregnancies/deliveries, two to seven women in every 1000
• increased risk of antepartum stillbirth, one to four woman in every 1000 (uncommon)
• increased risk in subsequent pregnancies of placenta praevia and placenta accreta, four to eight women in every 1000 .

I have looked at the consent advice for operative vaginal delivery on the RCOG guidelines, and while there are mentions of the increased risk of PPH that comes with a forceps delivery, it's not clear how many of these are serious. It does mention anal sphincter damage and vaginal abrasions. But nothing about hysterectomy, admission to ICU etc.

I'm assuming you have access to figures for serious morbidity following assisted delivery in the UK. Can you link me to them because I'm interested in seeing them.

Thanks!

Would want to add - that coming back to the issue of refusing forceps in labour, in order for doctors to help women make a properly informed choice, they'd really need to be very specific about comparing outcomes for emergency c/s performed in the second stage of labour with outcomes from forceps deliveries, and not just for emergency c/s as a whole.

"By all means talk about the risks of a CS, but don't pretend that forceps are safer or easier"

Sometimes they are, and sometimes they aren't.

Depends on many factors.

Which is all I've been saying all along!

It depends on many factors and if it comes down to a heart stopping hideous emergency situation the doctors will usually pretty much tell u what needs to happen.

The likely hood of this are very slim and people can tell u horror story after horror story about what happened to them
Or a friend of a friend, but really there's no need to worry until something worth worrying about happens if that makes sense?

This is from experience as I spent weeks
Stressing about what if this or what if that!!

Shagmund:

I think it's strange that you have deliberately chosen to ignore the plethora of research I posted earlier on in the thread. It clearly states that forceps substantially increase the risks of the following for the baby-

1. Erb's palsy
2. Cerebral palsy
3. Intracranial heamorrheage
4. Brain damage
5. Spinal cord injuries
6. Paralysis
7. Facial nerve palsy

For mum they don't just cause "perineal damage" as you insist, they are just as likely to cause infections and pph.(the link for which I've already provided)
as well as grave complications that require major surgery to correct.

I'm not surprised that RCOG doesn't mention ICU admissions etc. in the risks associated with forceps because they don't even talk about the above 7 risks I mentioned despite valid research that verifies every one of them. Neither does the NHS website mention any of the real risks of a forceps birth. They only mention 'mild bruising'. I have no idea what their agenda is behind this selective disclosure.

The links I've posted mention statistics related to assisted births for various demographics, not just UK.

This research proves that there is not much overall difference in infection and re-hospitalisation between assisted and CS births. So your insistence that CS cause higher morbidity isn't supported by research.
jama.ama-assn.org/content/283/18/2411.short

The link below states that a forceps delivery increases the risk of a pph substantially.
onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1987.tb02255.x/abstract

Meant to add Peace, that you have referred frequently to the fact that forceps are not used in other countries as evidence that their use in insupportable in clinical terms. Why do you assume that this decision is based on an accurate review of the evidence, when many of these countries also support obstetric practices which are definitely NOT evidence based - such as routine episiotomy, misoprostol induction for VBAC, and supine birth?

Also wanted to ask you which countries you were referring to in relation to a ban on forceps? My understanding is that they are used in Australia, USA, Canada, New Zealand.

In relation to all this have taken myself off to the Cochrane index of research into pregnancy and birth, which forms the evidence base for current NHS recommendations about best practice in obstetrics. I found one reference to research into outcomes associated with a 'trial of instrumental birth'. I've c&p'd the abstract below. As you can see, there haven't been any good quality trials so there is a dearth of reliable data on this issue:

notenoughevidence

Background:
The majority of women have spontaneous vaginal births, but some women need assistance in the second stage with delivery of the baby, using either the obstetric forceps or vacuum extraction. Rates of instrumental vaginal delivery range from 5% to 20% of all births in industrialised countries. The majority of instrumental vaginal deliveries are conducted in the delivery room, but in a small proportion (2% to 5%), a trial of instrumental vaginal delivery is conducted in theatre with preparations made for proceeding to caesarean section.

Objectives:
To determine differences in maternal and neonatal morbidity between women who, due to anticipated difficulty, have trial of instrumental vaginal delivery in theatre and those who have immediate caesarean section for failure to progress in the second stage.

Search strategy:
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2008).

Selection criteria:
Randomised controlled trials comparing trial of instrumental vaginal delivery (vacuum extraction or forceps) in operating theatre to immediate caesarean section for women with failure to progress in the second stage (active second stage more than 60 minutes in primigravidae).

Data collection and analysis:
We identified no studies meeting our inclusion criteria.

Main results:
No studies were included.

Authors' conclusions:
There is no current evidence from randomised trials to influence practice.

"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.

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:

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.

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

"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.

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.