Instrumental deliveries: never mentioned risks

[tstockmann]

Risks of faecal incontinence and pelvic organ prolapse both straight after birth and later on in life are common after ventouse and forceps.

You're probably going to check your pregnancy book and find nothing on this. I suggest checking the following pages:
forcepsthefollowonblog.wordpress.com/2014/10/28/what-i-wish-id-known-before-giving-birth/

www.patient.co.uk/doctor/faecal-incontinence (Scroll down to Aetiology-childbirth)

www.patient.co.uk/doctor/delay-in-second-stage-of-labour-and-use-of-forceps (Scroll down to Outcome)

www.patient.co.uk/health/genitourinary-prolapse-leaflet (Scroll down to What causes genitourinary prolapse? Childbirth)

The NHS Choices website does not mention any risks at the moment. This is wrong. They have assured me the page will be updated in February 2015.

Oh and I would interested to know if any organisations are campaigning for better aftercare for birth injuries, or trying to talk about them and make them less of a taboo, because that's something I'd definitely like to support.

Victim blaming?

The decision to attempt a trial is often taken when time is of the essence and the woman is exhausted and in silly amounts of pain.
I'm not sure a lengthy discussion is always appropriate.

Any delivery is not without risks.

"Risks of faecal incontinence and pelvic organ prolapse both straight after birth and later on in life are common"

Depends what your definition of 'common' is.

Incontinence and pelvic floor problems are not unusual in any older woman who's carried a child, no matter what the mode of birth.

"If you add the episiotomy and the overstretch from the forceps themselves, the damage is tremendous"

Actually severe and life changing damage caused by forceps isn't common. Most women recover well from a forceps delivery.

I'd also suggest that the reason why many women don't present at their doctors asking for repair is because many don't find it impacts on their quality of life in such a way that they can be bothered to do anything about it. I'd put myself into this category - shite pelvic floor and minor incontinence following a forceps delivery.

I agree minifingers, within the figures there will be some women with serious life limiting injuries, and others who are still injured but not enough to want to go through the palaver of getting it repaired. Even a term like faecal incontinence covers a wide range of scenarios.

And in saying that, I don't mean to diminish or dismiss any level of injury, just that the stats alone don't give the whole picture and you could easily read a worst case scenario into them which isn't necessarily there.

I had an EMCS (undiagnosed breech) - had no problems
I then had a VBAC with forceps - had no problems

I knew the risks of both but HAD NO CHOICE - baby needed to get out in both cases-

EMCS for breech because I had already had the epidural when they discovered the cause of my agony was a foot popping in and out of cervix - not me being a wimp

Forceps because the anaesthetist was dealing with "tricky twins" so I needed a local and forceps asap when baby became distressed.

People seem to think a lot more choices are available than in reality.

I'm not entirely sure what the point of this thread is, OP? Many women feel guilty enough about having to have an assisted delivery (I suffered depression after mine, feeling like a failure because I couldn't push my baby out - he had turned, there was no way he was coming out on his own.) I still feel guilty now and am dreading giving birth in a few months because of this. So yeah, thanks for informing me how risky my last birth was, OP. And thanks for making women feel even more shit for using an epidural. I was so dehydrated and exhausted from non stop vomiting for 36 hours, I would never have had the energy to push my baby out at all without the 2 hours rest at the end I got from the epidural.

It's all well and good "promoting natural, drug free births" but quit making other people feel shit in the process.

Oh Blueberry it sounds like you've had a horrible experience. So sorry to hear that and I hope you are ok.

As I said before, of course I, like most people, would never "choose" to have an instrumental delivery. In fact, I would choose a pain free, damage free magic spell, which would deliver my baby for me please...

I do find the onus which is sometimes placed on women to "choose" the best options for birth occasionally counterproductive; as if to say, "Oh well done you, your straightforward birth with no injuries was clearly because you chose the right mode of birth" or "oh silly you, you should have pre-empted this and fought with highly trained medical professionals to insist on a c-sec".

Obviously a degree of choice is good, I just don't believe there always is a choice regarding instrumental deliveries - sometimes it seems to be a case of getting the baby out right then and there or risking life-threatening injury to mother or baby. Under those circumstances I would rather take advice from the HCP who is actually there at the time regarding the method instead of consulting my pre-prepared risk assessment of the various options.

As PPs have said - child birth is a risky business. This thread could almost have been titled "Child Birth: never mentioned risks". C-sec, forceps, ventouse, waterbirths; I have now read about all of these options apparently being responsible for significant injury to numerous birthing mothers. Surely it depends on each individual case rather than the method in that case..?

If there is a campaign for better aftercare I would find that really interesting.

To me the point of this thread is that pregnant women are treated like idiots.

Yeah I'm ok thank you, I talked things through with my consultant recently as I'm currently 20 weeks pregnant and was struggling with being worried about it all happening again. I agree that a campaign for better aftercare is an interesting idea, as often it's the aftercare (or lack of) that separates those who are at peace with their birth experiences and those struggling to come to terms with it.

I think it's very important for health professionals to explain what the research suggests about how birth settings, patterns of care and pain relief choices might impact on the chance of having an instrumental birth/unplanned c/s.

Would add - much as I'd like to see more resources put into postnatal care, it ain't going to happen. It's just not.

I see your point OP and I agree with it. No one chooses an EMCS or forceps, when you need them you accept their use but the OP is right that when it comes to discussing birth options when many women have a choice the risks of CS are over-emphasised while the risks of VB are under-reported. That is hugely problematic because choice that is not informed is not choice.

'That is hugely problematic because choice that is not informed is not choice.'
Well said Booboo.

I'm not sure that the risks are 'over emphasised' - that is a matter of opinion not fact surely?

I think the key thing is that women who are opting for elective surgery have time and mental space to learn about all the important clinical risks.

Unplanned c/s, forceps and ventouse are done in a very different situation and it impacts on the ability of the woman to really make a free and informed choice.

Risk assessment is always a subjective evaluation, but that doesn't mean that there can't a reasonable, gereral ranking of risks.

Given that the most common risks of CS are bleeding and wound infection, both of which can, in most cases, be addressed, while the most common risks of VB with complications are hypoxia and neurological problems, neither of which can be addressed, it is reasonable to say that the risks of VB with complications are greater. Yet medical information stresses the risks of CS and often doesn't ever include risk assessment information for women who opt for VB.

Sorry just to add, I am not referring to emergency situations for either birth option, because clearly circumstances may make informed consent impossible. However I do think that all women should be given detailed information on all birth options before they go into labour when there is time to reflect and chose. Anyone who thinks that ignorance is preferable for them can always opt out.

"Given that the most common risks of CS are bleeding and wound infection, both of which can, in most cases, be addressed, while the most common risks of VB with complications are hypoxia and neurological problems, neither of which can be addressed, it is reasonable to say that the risks of VB with complications are greater"

Can you link to the information you're are getting your facts from?

here

The NICE guidance - consent information (page 22/23) doesn't support your assertion AT ALL.

In any case - it's a nonsense to think you can compare them in the way you have, because the comparative risks and benefits are strongly affected by:

• whether it's a woman's first or subsequent baby
• whether the mother is low risk
• the type of intrapartum care the mother has.

I'd also want to flag up the fact that a great deal of the research comparing outcomes for mode of birth is done in obstetric settings where the vaginal birth cohort have the type of care which results in high rates of instrumental births and unplanned c/s - all of which contribute to poorer outcomes in the vaginal birth cohort than might reasonably be considered with optimal care which supports the normal physiology of birth.

"Given that the most common risks of CS are bleeding and wound infection",

NICE

                           ELCS               Planned VB (including emcs)

Bladder injury: 0.1 0.003
Hysterectomy 0.8 0.02
Admission ITU 0.9 0.1
Maternal death 82.3 per million 16.9 per million
Antepartum stillbirth 0.4 0.2
in subsequent
pregnancy

Annoying - table didn't copy. First set of figures are for planned c/s. Second set of figures are for planned v/b (including emergency c/s)

Bladder injury: 0.1 0.003
Hysterectomy 0.8 0.02
Admission ITU 0.9 0.1
Maternal death 82.3 per million 16.9 per million
Antepartum stillbirth 0.4 0.2
in subsequent
pregnancy

Booboo, sorry - don't want to repeat what minifingers just said but would like to know where you got this please:

the most common risks of VB with complications are hypoxia and neurological problems

My information comes from comparative studies of different birth methods found on google scholar or similar search engines.

While different birth methods carry different risks for mother and child making a strict comparison difficult, the ranking of risk in general from less to most risky is

VB no complications
ELCS
EMCS
VB with complications

VB with complications is at the bottom of the list because of neurological and other problems associated with the use of forceps and delays in labour that result in hypoxic injuries to the baby.

The best studies on this topic distinguish between EL and EMCS, have data from countries with high EL rates (Brazil, China, US) and are relatively recent to include larger numbers of CS in the last decade.

If DS wakes up in the middle of the night and I am not incoherent with sleep deprivation I will try to find some direct links for you.

I don't quite get the relevance of the link above. Not only is it 10 years old but it doesn't even compare birth options which I hake is part of the point the OP is trying to make. The document outlines the risks of CS without setting it within the context of the risks of the alternative.

Mini fingers - I'm not saying that I know much about the risks, but those stats don't really compare like with like. You'd need a set of stats that only included women/babies for who a VB would be appropriate for both the ELCS group and the VB group. Otherwise you are effectively comparing women/babies with known issues with those without.

I'd really like to see the stats for induction vs ELCS.

Links please Boo.

The document I linked too is current guidance.

I'm still not sure what you want women to be given in relation to informed choice, or how or why.

The how and the why are particularly important.

Would also like to know what the value of telling women about specific risks of forceps/ventouse if you can't compare them with the risks of doing a late second stage emergency c/s (because that's the only specific comparison which wold be of use in relation to informed choice - they already have access to the overall comparative safety of c/s and planned v/b.

mini the guidance you linked to is the 2004 document and has been replaced by the 2011 document see here
www.nice.org.uk/guidance/cg132

What I want is fairly simple: information on all types of birth should be standard as prt of antenatal care.

The value of telling people about the risks of forceps/venduse antenatally is that they can then chose CS and thereby avoid both VB with complications and ELCS. VB without complications is the best option in terms of risks but the 'no complications' bit cannot be control so for some women the subjective risk assessment will be to chose ELCS in order to control the risk of graver complications.

Here is some more informations:

• the risks of forceps causing neurological problems is quite well known and accepted, see indicative studies here link.springer.com/article/10.1007/s00404-007-0465-7

www.sciencedirect.com/science/article/pii/S0002937801985357

• clearly there are no studies comparing intrapartum asphyxia in VB and ELCS as ELCS takes place before the commencement of labour so by definition won't be implicated in intrapartum asphyxia. This indicative study gives you an idea of VB complications that tend to lead to asphyxia

onlinelibrary.wiley.com/doi/10.1034/j.1600-0412.2002.811003.x/abstract

• for a direct comparison between planned CS and VB likely to have complications see on of the many articles recommending ELCS for breech presentation exactly because of the risks to the foetus with complicated VB

www.sciencedirect.com/science/article/pii/S0140673600028403

More to come, just posting this so I don't lose it! (Baby thrashing about and hitting iPad!).