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.

Other NICE recommendations which are currently not being taken up by hospitals across the board - all women should have 1 - 1 care in labour, all women should have access to a birth pool, women who present with PND should be offered a course of CBT and not just antidepressants... It goes on and on, lots of recommendations which aren't being followed because the NHS doesn't have the money or the staff.

We'll I never used the word 'rules' so I am not sure what you are sorry about. NICE guidelines recommend women be given the choice because they recognise they should have the choice, it's a normative argument about the importance of choice. In practice many things that are recommended are not in fact offered for whatever reason, e.g. cost, availability of equipment, availability of skilled professionals, etc but that is merely further reason to strive harder for change.

If you want to make an argument about which deficiencies should be addressed first then it needs to be much more complex than what you suggest to be successful. A refusal for CS can have financial, emotional and policy implications as significant as shortcomings in other areas of care.

Like any health funding, it's a question of providing priorities and IMO the decision has been made that offering women genuine choice as to how they would like to give birth - including an ELCS if that is what they would choose - is not a priority.

The closer I draw towards my ELCS date, the gladder I am that I am in position to pay to go private and choose an ELCS but I don't think it's a fair system at all. I've made an educated, informed choice about the risks and I feel strongly that ELCS is the best option for me. (There are no medical reasons for me choosing it.) From my experience, unless you go looking for more detailed information, the info you are offered re birthing options tends to compare best case VB with worst case CS (e.g. conflating EMCS and ELCS) and the risks of bad tears and forceps is barely mentioned. For me, the known risk of planned surgery in the abdomen was preferable to the unknown (or should I say, more difficult to quantify in advance) risks of birth trauma or emergency surgery. I am a pessimist though!

"From my experience, unless you go looking for more detailed information, the info you are offered re birthing options tends to compare best case VB with worst case CS (e.g. conflating EMCS and ELCS) and the risks of bad tears and forceps is barely mentioned."

I have to completely agree with this. I had an elective section as previous surgery meant I had scar tissue in my pelvis and the risks of severe birth injuries were a lot higher for me than the general population. Before this was agreed by the consultant however I had to discuss the 'birth options' with a junior registrar who insisted on listing all of the possible negative consequences of a C section including hysterectomy and uterine rupture in subsequent pregnancy, but who failed to mention, at all, any risks with vaginal delivery. I queried again the pelvic scarring, the consultant was involved, and a C-section was agreed immediately as a vaginal birth was far too risky. I hate to think what would have happened to me if I'd just gone along with her suggestions.

I think the other thing which is of great significance is that low risk women who want an ecls also form a group who are unlikely to opt for the models of care which are associated with the best clinical outcomes for vaginal birth - namely births outside of an obstetric unit, so the stakes for them are different than for many others.

I have absolute sympathy for women who want a ELCS whose other option is a managed vaginal birth in an obstetric unit with very high intervention rates. Only about 1 in 3 of those women will have a birth which doesn't in some capacity involve instruments, so you can see the argument for 'cut to the chase' with an elcs.

Well I would never give birth outside of an obstetric unit because the risks are unacceptable to me. I don't think that makes me right and the choice of someone who chooses to home birth or give birth in an MLU wrong - I think think it means we have different priorities, different circumstances and different risk assessments. My decision is right for me, but the only way I'm guaranteed to have the birth I want is to pay to go private. It seems unfair that someone who shares my view of the risks but can't afford the private care isn't afforded the same choice.

A woman needs to go where she feels safest, but it's really important that she does so in the knowledge of the facts about safety.

Well obviously

And based on the facts many women would prefer to give birth in an obstetric unit or even have an ELCS (as I am doing). Currently whether you have a real option to choose the latter depends on whether you can pay for it.

"And based on the facts many women would prefer to give birth in an obstetric unit or even have an ELCS (as I am doing)."

You mean if you show low risk women the evidence that if they go to an obstetric unit they are

• more than twice as likely to have an emergency c/s
• twice as likely to need forceps or ventouse to deliver their baby
• three times as likely to have an episiotomy
• twice as likely to need a general anaesthetic
• no more likely to take home a well baby

..... than if they choose to labour in a freestanding midwife led unit (or if they are having a second or subsequent baby, at home) they'd STILL want to give birth in an obstetric unit and believe that they are safer there?

I'd suggest that most women aren't aware of the evidence regarding the risks of hospital birth.

minifingers, do your statistics take into account the facts that obstetrics units take in all the women with non-straightforward situations and difficult pregnancies, while midwife-led units and homebirths have a pre-selected pool of women with straightforward situations?

if I have a high-risk pregnancy, I will probably want to give birth in an obstretrics unit. But if I then go on to have a C-section, was it because I was in an obstretrics unit, or because I was high risk to start with?!

oops sorry just saw you wrote "low-risk women"

would you have a source for your stats please?

here

2011 - it compares outcomes for low risk mothers who were low risk at the start of labour according to planned (not actual) place of birth (which is how they arrive at a figure for c/s rates for home births (because women who plan a home birth don't have a c/s at home....)