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.

Briefly:

• this a useful summary of the idea that VB is the safest option, but VB with complications raises risks which are avoided with ELCS

www.cmaj.ca/content/170/5/813.short

-comparison between CS and complications in VB
onlinelibrary.wiley.com/doi/10.1034/j.1600-0412.2003.00194.x/abstract

That will have to do for now. Will check but on this thread but may not be till tonight.

But with respect Boo - if women aren't being offered an alternative to the default mode of birth (physiological birth) then where is the value in pouring over the minutae?

Particularly as the comparative risks and benefits vary hugely according to a) parity and b) the type of intrapartum care labouring women are given. In the US and many other developed countries, with up to 1 in 3 women being induced /augmented in some hospitals, supine birth, 95% epidural rates, routine ARM, routine episiotomy - well, we're not comparing physiological birth with surgical birth....

Also - would suggest you google 'Microbirth'. There's all sorts of interesting research and questions being asked about the long term consequences of meddling unnecessarily with the normal physiology of birth, questions which studies like the ones you link to don't even begin to consider.

Well I thought the point of the post was that women should be better informed so they can chose alternatives - apologies OP if I misunderstood this. As for the availability of options, in the UK women can now request a CS, as if the case in the US and Greece for example ( at least in private care), whereas in other countries like France ELCS is not available.

No studies consider the micro birth claims so it's kind of tough to decide one way or another. In any case the response to 'but there is more information on other options' is surely 'let's learn about all of it', not 'ok if there is info on microbirths there is no need to learn about VB complications. I don't have an opinion on the birth choices women should make and frankly I don't care. They can chose free birthing or ELCS and everything in between. I do think that the information for making this choice should be standard lay available to anyone making minimal efforts to access it, e.g. Antenatal care.

Boo what you're saying is all well and good bit sometimes an instrumental birth is needed after it would be too late for a c section. Ds started turning as he was coming down the birth canal and got himself into an awkward position, but it was far too late for a section. Risky things can happen in labour, and handing out c sections to every woman is not the answer.

'Handing out'? Women are not infants or incompetents to be handed out anything, they have the right to chose what happens to their bodies. And while emergency decision making is constraint by the emergency, pre-planning is not. To make it clearer: I think that antenatally you should have been informed of the possibility of your DC getting in an awkward condition and not having an EMCS as an option with all the risks that carries; it would have been up to you to chose VB fully informed then. I hope all was well in the end with the birth of your DS.

There are many more risks to the baby becoming apparent with CS births - which are related to the fact that the baby has not descended the birth canal - allergies, asthma, chest problems etc.

(Anecdotally my CS child has always had many more problems related to breathing than my VBAC child - chest infections after even the slightest sniffle, allergies etc etc etc ...)

"To make it clearer: I think that antenatally you should have been informed of the possibility of your DC getting in an awkward condition and not having an EMCS as an option with all the risks that carries; it would have been up to you to chose VB fully informed then. I hope all was well in the end with the birth of your DS."

The vast majority of ALL births - surgical and otherwise - have a good outcome in a population of healthy women who've had access to proper antenatal care and care in labour which supports physiological birth.

That would be the starting point. Anything else is pointless fear-mongering. And information (like the studies you link to) which doesn't adjust for parity or quality of intrapartum care for labouring women is really not very helpful when it comes to informed decision making.

"it would have been up to you to chose VB fully informed then"

But if the NHS isn't offering elective surgery as an alternative to labour then what? What is the function of that talk? What impact would it have on women? Or is that something you're not bothered about? You don't 'choose' a vaginal birth. It's what happens if you aren't given the option of surgery.

"No studies consider the micro birth claims so it's kind of tough to decide one way or another."

Yes - it's hard when the research into the long term impact of surgical birth is so limited and so lacking. Would you tell women this as well? That there are many things we may well not understand about the long term impact of meddling with the birth process?

As an aside, I think the term CS itself should be banned -

We have already changed Assisted VB to Instrument intervention birth, makes it "sound" horrid - so why not a Surgical Intervention birth.

"Banned"?

Isn't 'surgical birth' ok?

Oh, and this is the first time I've heard the phrase you say is now commonly used to describe forceps/ventouse. Where do you live? In the UK we talk about 'assisted delivery' or 'forceps/ventouse birth.

I read an article recently (sorry, can't remember where, have been pouring over articles relating to birth injuries every day for over a year now) saying that there are now a record number of menopausal/post-menopausal women being treated for prolapse and other conditions which can be traced back to VB. Interesting as the women in this age bracket would have been giving birth in the years immediately following the introduction of epidurals and the increased medicalisation of childbirth in hospital settings.

neef - I think it's hard to compare like with like. The 1970s were the time of 'Active Management of Labour', where the syntocinon drips were put up pretty routinely and turned up high, women were usually giving birth flat on their backs, or at best, 'semi-sitting' and were being yelled at to push, push, with strict time limits applied, plus the routine episiotomies (which were supposed to prevent prolapse?). Plus epidurals were less finely tuned than today - no such thing as a 'walking' epidural then, so you would likely be too numbed to be able to feel to push.

In short, labour was a game of beat the clock for many women - so how many injuries are as a result of the aggressive way that labours were managed then? (I don't know the answer, it's a genuine question.)

What we won't know for a number of years is what effect the increase in CSs will have - will we see a reduction in prolapses in the years to come?

And to add - possibly more women are coming forward for repair work now than formerly. My own mother had her bladder damaged in childbirth which she just put up with for many years - either there was no treatment, or she didn't realise that there was. I am sure that she was typical of many.

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.

Studies which are in themselves flawed because they differ from medicine in the UK. They are useful in someways and make the case for ELCS but they are more limited than you suggest. I am assuming that you are probably in possession of Pauline Hull's book... where she touches on the problems with all of these studies from a British POV.

For example, Brazil has a situation where the CS rate is so high, there has been a deskilling in difficult vb deliveries. CS are still encouraged for women who have numerous children which brings with it, its own complications. This also means that women have restricted choices and not the freedom of choice we would like.

The US healthcare system is deeply flawed and any data is somewhat distorted as a result of that. Women who choose an ELCS have to money (and therefore a certain lifestyle) and/or the right health insurance. And there are also higher rates of obesity... and midwives and training in obstretics is fundamentally different; you are certainly not comparing like for like with the NHS.

And China, with its one child policy, there are fewer issues with repeat CS complications. Its health care for women has also improved with a massive cultural shift for women to go to hospital. And with the sheer number of births, an ELCS is easier to schedule...

What we really need is data relevant to the NHS model of care if we are talking about informed choice. Or at least data that is more culturally relevant (ie from Western Europe).

I find it deeply frustrating that we are not even recording data in this country to make this possible at present. Nor do we record reliable data about tears. Certainly not with regard to long term complications and certainly not about mental health as well as physical.

From this point of view, both sides of the debate can pull numbers and fingers out of their arses, neither of which make it much easier for women to get a clear picture of what is 'best'. Nor do these sides usually pay much heed to the generalised nature of the risks of both and acknowledge that its unevenly distributed meaning that some women will have that risk stacked differently based on their own personal circumstances. And I do think this is something that is crucial to anyone's understanding.

The whole debate requires a good understanding of statistics and risk. Something that is something of a skill in its own right. I do believe that the majority of HCP probably don't understand this, in a way that's truly beneficial to enabling their patients to make an informed choice (indeed I have seen that there has been research done recently to back up my assertion here).

Crucially though, I do think there does need to be more awareness about the risks of instrumental deliveries AND substantially more support for women who encounter them. But in a neutral way, without necessarily promoting ELCSs in the process. I think its very easy to neglect the statistic that if you attempt a VB you may for example have an overall 9% chance of 3rd or 4th degree tear (it might be lower if you are in certain lower risk groups) but if you attempt an ELCS you have an almost 100% chance of major surgery (an unplanned speedy vb being the only way its not).

I decided a while ago, that on balance, with all the information we have currently there is very little difference in the overall risks between a planned vb or a planned ELCS. What is far more important and relevant is looking at your own individual circumstances and risk factors and indeed considering your ability to cope with certain scenarios.

"I decided a while ago, that on balance, with all the information we have currently there is very little difference in the overall risks between a planned vb or a planned ELCS."

Good post BUT I assume this comment (above) applies only to your own circumstances, and isn't a general judgement on comparative risks of vb and elcs?

Because if you held this up as your conclusion in the round, I'd be asking - for whom?

• a first time mother of 41, who has opted for a medical induction at 40 weeks on the labour ward of a hospital with a c/s rate of 33%?
• a healthy mother of 26 having her second baby at home with a team of caseloading midwives, following a straightforward first birth?
• an obese mother of 29 having her third c/s following a previous episode of placenta accreta?
• a healthy first time mother having an elective c/s at 39 weeks?

The rate of normal birth (ie - birth without episiotomy, instruments, augmentation, emergency c/s etc) for women falling in the first group will probably be around 30%.

The rate of normal birth for the second mother will be massively higher. For women aged 24 - 29, expecting their second baby in a non-obstetric setting, the instrumental delivery rate is 1.7% and the emergency c/s rate is less than 1%.

Puts a different complexion on the balance of risks and benefits of v/b vs elcs, when you're not assuming a normal birth rate of less than 50%?

LaVolcan everything you describe as the 1970's 'Active Management of Labour' happened to me in 2013. Syntocinon drip put up because my waters had been broken for over 24 hours - even though my contractions were progressing naturally, I was birthing in a semi-sitting position because of the 'walking epidural' which certainly didn't allow me to move enough for what I would describe as an active labour, and I was being yelled at by three midwives to push once I was fully dliated - even though I couldn't feel a thing to allow me to push. I felt frightened and helpless and 'managed' rather than having any control over my labour.
There have been several studies that have now disproved the theory that routine episiotomies reduce prolapse - and they have been proved to increase the likelihood of a third or fourth degree tear. This is why they are no longer routine and are now usually associated with an instrumental birth - taking us back to the damage caused by forceps..

Mini, if you read what I said, I don't need to qualify further, because I said all that in the post.

I said on balance for the 'overall risks' and then added the subsequent cavat of personal circumstances and risks loaded unequally and that looking at your own circumstances was the key bit.

You've just provided a few examples for exactly what I'd already said minus all the stats that you can easily drown in .

I don't think there is any point in getting massively bogged down in the stats anyway, because whilst you may be in one group, you may perhaps have suffered a traumatic previous birth - in which case, they may be a consideration but not the only thing to consider.

Even taking your example of a first time mother having an ELCS at 39 weeks, a woman of 20 may have very different considerations to a woman of 36. Namely what her general health is, how many children she wants, what her mental health is like... You can carry it one to the nth degree. Ultimately it comes down to what's right for you and often the stats don't cover a great many of those aspects and it becomes a balancing act.

So going on the overall statistics - despite the fact that women having a planned c/s are more likely than women trying for a v/b
-lose their wombs

• suffer a stillbirth in a subsequent pregnancy
• end up in ITU
• die

even taking when you include those who have an emergency c/s in the vaginal birth cohort, you STILL think that planned c/s is equally safe for women?

I think the absolute risk is still small. It is an increased risk, but the size of that risk is relative and that's the important bit. The risk of dying in the UK, whether it be through a planned vb (which includes EMCS) or a planned CS is very small, full stop.

This is what I mean about understanding risk and statistics.

You are also discounting certain things; for me as a woman who was planning a family of only one child, the risk of losing my womb was not something as I was as concerned about as other risks more commonly associated with a vb for example.

I'm sorry, but you are trying to pick at things rather than recognise that there is always a risk; you have to understand what that risk actually is and what is the risk you are prepared to take and that not all people will make the same judgement. It doesn't make one 'right' and one 'wrong'.

I find it very interesting that in several studies its been shown that doctors would often take different treatments for themselves which they wouldn't recommend to their patients. They are more likely to take a treatment which could endanger their life more but have better long term outcomes, than one that might not carry as many risks, but might have long term consequences such as paralysis. Why is that?

To me that shows that different people simply are prepared to assess and take different risks according to their circumstances and what they feel they could cope with/live with. In the same way that some people might ride a motorbike or jump out of a plane and others wouldn't.

It doesn't make one 'right' and one 'wrong'

Yes, I agree with that. This is what kind of irked me about this OP tbh. It seems like some people argue for one type of birth over another type. Perhaps I was reading too much into it, but the OP itself read to me as if forceps = damage - fact and should therefore be avoided in favour of..?

I imagine that the best birth method is completely dependent on the case and that there is no one size fits all, guaranteed, safe method of delivery. I am never likely to agree with people who, (despite apparently posessing no medical qualifications other than an ability to use Google), make generalisations in order to slam one birth method over another. That is not directed at the OP or anyone else in particular, it is just something which really bothers me.

I have not made any value judgements.

Why are you suggesting that I am?

I have said nothing to suggest that I don't understand risk in terms of its magnitude.

I was simply questioning how you had arrived at the conclusion that VB and ELCS are - on balance, and disregarding individual differences - equally safe.

And I agree that everyone had their own comfort zones around risk taking.

mini I am failing to follow your argument. The NHS IS offering a choice, no one said that risk should not be adjusted for individual circumstances, you make claims with no references despite asking them of others and see to have a bee in your bonnet about promoting VB. The whole point of risk assessment is that it is subjective, some people will make choices you think are unwise, the important aspect of decision making is for each person to make genuine choices, I.e. informed, reflective, free choices.

Who has said that CS and VB are equally safe? I can't spot that in the thread, could you please point it out?

I do not understand the argument that there is no benefit to adversing the risks of instrumental delivery. Even if it doesn't change the outcome, it makes a huge psychological difference if you are well informed, prepared for all eventualities, and aware of the risks.

I had a forceps delivery resulting in a 3c tear, and in the next few days in hospital I had the pleasure to discover that I absolutely could not control my bowel movements. Having been warned in advance of the risks would not have stopped me shitting myself, but it would have normalised the experience - "this is something that unfortunately sometimes happens", as opposed to "oh my god what is happening to me, I'm so ashamed, my life is over".

Incidentally, there is not always a choice between forceps and c-section, but sometimes there is. In my case, there definitely was, and I was just informed of the decision to use forceps as a fait accompli, without any explanation of the comparative risks involved. I'm not saying I would have chosen differently at the time, but it would have been nice to have been informed.