Forceps and Third Degree Tear has ruined my life - why does nobody talk about the risks?

[neef]

I am starting this thread because I cannot believe that no other first time mum has experienced what I am going through, and I cannot believe that the medical profession lets women suffer these injuries in the 21st century. Why isn't Mumsnet all over this?
I am two years on from childbirth and I have lost all sensation in my perineum and outside of vagina. I am suffering prolapses and bowel leakage despite doing millions of pelvic floor exercises and spending hundreds of pounds on women's health physio. I have severe pelvic pain after exercising or even just standing for any period of time. My life will never be the same again.
If I knew of these risks beforehand I would never have consented to vaginal birth and would have insisted on ELCS.
What can we do to stop this and anyone else out there suffering with me?

I had a normal first birth. It was quick and easy, but I tore down the back vaginal wall. There was no skin tear there (that was all at the front ) so I had one big stitch put in through the skin.

I was sure it was not right, but a midwife checked and said fine. GP at 6 weeks check said I had healed well (must have just looked at skin). I was not very happy with my bits, but everyone says it is different after, and I could not say what was wrong.

After 20 years of difficulty pooing and tampons falling out, I realised from reading on here and looking at the CH4 embarrassing bodies that my bits were just not right. The ring of muscle around the vagina had torn and pinged back, I had very little perineum and I could feel a deep tear between the vagina and rectum, where there was only thick skin. (now there is a big wodge of muscle). Apparently this is very common.

I had the back wall repaired, perineum rebuilt and reattached to rectovaginal fascia. I had it done quickly on DH's health insurance but it is available on the NHS. I don't know why they can't just examine and repair you properly in the first place.

I had Elcs as I felt that the risks of vaginal birth were being underplayed to me and I didn't trust my hospital to provide the right (ie continuous) support and monitoring to make a successful vb likely. I was lucky to have that choice. I'm sorry you are putting up with so much and yes, this should be an MN campaign. We should talk about what we go through to bring children into the world.

Yes, i agree about a mumsnet campaign - but the focus should be on the medical profession taking it seriously when women suffer trauma, both physical and mental as a consequence of birth - whatever the method of birth. The focus on ELCS being the trouble free option if you want to avoid physical damage, is a misguided one IMO.

Hang on for two seconds. I think before anyone gets carried away I think we need to have a discussion about cause and effect. And then one on politics, ideology and accountability. Even on this thread there is a certain amount of bias and inaccurate information that needs clarifying. I think seeing an ELCS as the solution to problems is the wrong solution to the wrong problem.

I had an ELCS for anxiety reasons. As a first time Mum. By choice. However I did a hell of a lot of research before going down that route and there is a huge amount of misinformation going on. This SHOULD NOT be framed as a planned VB versus a planned ELCS choice. Especially since the evidence based medicine out there leaves a lot to be desired and does have massive gaps which need to be examined.

First of all, having had an ELCS for mental health reasons, and doing a lot of research I have a certain amount of knowledge about women who have suffered trauma for their first birth as there is a certain amount of cross over for the two subjects. Trauma can be suffered by anyone regardless of how you give birth which includes a 'textbook' vb. You don't have to have a physically 'bad' birth to be traumatised by it. At first this sounds like this has nothing to do with the OP but bare with me on this.

If you start to breakdown the reasons for trauma, you start to see patterns regardless of physical outcomes. Poor communication, women not properly involved in decision making process, poor staffing, process and policy more important than individualised care, overly defensive practice or a strong culture of trying to avoid CS at all costs. I could go on. My point here is that the way you actually give birth is only one part of it.

If given help and support the second time around women with anxiety related issues who request an ELCS first time round can go on to change their mind and have a normal VB. Why is this significant? Because it suggests that really birth management is a much bigger factor in risk than we are really giving credit for here.

Off the top of my head I'm going to look up some stats for a few larger hospitals. All consultant led in big cities. So Liverpool, Manchester, Leeds, Birmingham and Bristol (I'm going to deliberately leave London out for a few reasons).

Liverpool Womens
36.20% had unassisted vaginal deliveries

14.30% had an EMCS
12.50% had an ELCS
14.40% gave birth with the aid of instruments

33.20% were induced

Manchester Wythenshawe Hospital
39.90% had unassisted vaginal deliveries

15.70% had an EMCS
12.80% had an ELCS
12.20% gave birth with the aid of instruments

24.00% were induced

Leeds General
45.40% had unassisted vaginal deliveries

10.70% had an EMCS
9.70% had an ELCS
12.80% gave birth with the aid of instruments

25.00% were induced

Bristol St Michael's Hospital
38.10% had unassisted vaginal deliveries

11.70% had an EMCS
12.00% had an ELCS
14.90% gave birth with the aid of instruments

31.80% were induced

Birmingham Women's NHS Foundation Trust
52.70% had unassisted vaginal deliveries

16.80% had an EMCS
10.20% had an ELCS
15.90% gave birth with the aid of instruments

0.10% were induced

It frames things a certain way and judges hospitals in a certain way. The data we see and how we make judgements from it is important. Where in the above is the data on 3rd or 4th degree tears? Its not there so how can the public and the NHS hold individual hospitals accountable for high rates? If you try and google what percentage of women have 3rd or 4th degree tears then you'll find very vague references which estimate it. Not give data, estimate. So there is problem number one.

Problem number two is the pressure hospitals are being put under to reduce C-sections. This is without regard to what a woman would prefer and what she may feel is the best option for her. This puts doctors in a difficult position. They are caught between the politics of above and the best interest of their patient. It is something of a conflict of interest and the question has to be asked about how this is being balanced and whether some hospitals are getting that balance right better than others.

At no point in the above does it state whether women felt like they were listened to and involved in decisions about their care. No where can you find policy with regard to maternal requests and whether women are being refused them or not. A woman refused an ELCS or who finds it difficult to get an ELCS may be very dissatisfied with her care. A woman who has an ELCS on the advise of her doctor - and doesn't agree and thinks they are practising defensively - may not be happy with the outcome. This is important.

The drive to reduce CS is based on a few things; an outdated and now redundant WHO target which has since been replaced by the advice merely that anyone who needs a CS gets one and the assumption that CS are both costly and risker than VBs. In fact CS are neither good nor bad and should not be viewed in this way. Until we stop framing them like this then women will always suffer as a result regardless their method of birth. It should only ever be about whether the CS or VB was the most appropriate method for the circumstances that each individual patient presented with. At present that is not happening.

If you look at the above figures there is something odd going on. Even allowing for variations in demographics, why on earth is Birmingham so different to other hospitals? The only answer can be down to management of labour. On the surface it looks good having the highest number of unassisted VBs and a very low induction rate, but conversely its EMCS rate is much higher than elsewhere AND it has the highest rate of instrumental deliveries. Birmingham's figures make me raise my eyebrows.

This wide disparity of care throughout maternity the figures above seem to suggest has also been born out more scientifically by the findings of the huge place of birth study done a couple of years ago. Why were women who were classified as low risk having such different outcomes depending on whether they gave birth at home, in a midwife led unit or a consultant led unit?

Also women requesting ELCS for anxiety are usually given the reason as 'maternal request' which belies the fact that it might be for their mental health. This is incredibly misleading in data collection and then subsequent decision making. Anyone who looked at the raw data for the hospital I gave birth at would have be filed under maternal request. This is despite the fact that my consultant midwife went to great pains to emphasis that I had a need (not want) for an ELCS and it was clinically indicated.

Picking up on the comment After a natural birth with no complications at all (which is down to luck sadly), a planned section is the second safest option. someone put earlier I think it does have to be put into context. Whilst that's true for first time mums the risks change a great deal for subsequent births depending on how you gave birth. If you have a planned CS then risks go up every time after. If you have a planned VB - even with instruments - then risks go down. It is therefore misleading just to say that a planned ELCS is the second least risky.

So going back to the OP and what she said about being told the risk of a VB potentially being serious tearing. She can't be informed properly as the data isn't available to make an informed decision. You can't legally withhold consent for a VB because the law is against interventions and you can not legally force a medic to carry out an invention.

And going back to what I said about poor treatment of women resulting in mental health issues, there are parallels with the reasons for this being an outcome and the reasons for poor physical outcomes.

The major surgery of an ELCS is not the solution for many of these problems nor for every woman. Its greater accountability, transparency, training, education, politic and ideology being put second to the patients individual needs, treating women as individuals rather than statistics, better staffing, more involvement with women in their care, better communication... I could go on.

Its not about informing women that they might be at risk of tears. It should be about finding out what risk factors there are, identifying if an individual is more at risk and how those risks can be reduced and then making an informed decision about what the most appropriate course of action might be on a case by case. None of which can be done without recording information about tears that is currently not being done at present. And the follow on from that is poor recording of why women are having ELCS (which includes for mental health reasons).

So I think a MN campaign needs to purely be about raising standards of care, research and promoting women centred care. Nothing more. Nothing less.

/rant.

Been there.. It's been 20 years since I had sensation during sex and have had the problems that come with prolapse.

Get it seen too sooner rather than later though.. It won't improve on its own.

OP - I had the same as you. You have to keep at your GP to refer you to a specialist.

TMI - the only way I could poo was (as someone on here put it so eloquently!) by "digital manipulation". I believe the kind of forceps I had are no longer allowed in the UK.

I did go to the GP. First time I was told "I was healing beautifully" and a bit of incontinence was to be expected and that was "being a woman". "Keep doing the exercises". This was a female GP.

It was unbearable - I really did feel my insides were falling out - and went back to see another GP. He referred me right away and the surgeon told me no amount of pelvic floor exercises could repair the damage. I had quite a major pelvic floor repair op within 2 weeks of seeing the consultant.

The difference was immediate and incredible. Thank heaven for a sympathetic GP.

Due to being predicted a big baby and having M.E (so I will tire quickly), I had sort of "accepted" I would probably need assistance in the form of forceps etc. However, reading this thread has been really eye opening for me.

I had no idea of the risks at all, and as others have said, it certainly wasn't covered in ante natal classes! I am writing my birth plan out atm, and will make it very clear that if it becomes obvious assistance is needed, I would rather avoid instruments and go straight for a c-section.

I'm really sorry to hear about your health OP. All I can say though, is thank you for starting this thread and sharing your story, so that FTM's like me can be more informed. [Flowers]

This is why it bugs the crap out of me when natural birth advocates and public health officials talk about the c-section rate like it's the be-all and end-all. The reality is that there will always be a proportion of births that require assistance. In many cases if there is no c-section then the alternative is instrumental delivery and that is most certainly not without its own risks. Forceps is rarely used these days in the U.S. for that exact reason. C-section risks are more predictable and generally the baby's saved even if the mother has complications from surgery.

I had a forceps delivery first time around with my DS and was very lucky to have no tears or complications. I did have a large episiotomy though and it still causes me some pain now and again 4 years later.

I totally agree with you OP that the risks of a difficult vaginal delivery are not emphasized enough to women. There is this concern about 'alarming' women unnecessarily but we're not children! We should be just given the facts in antenatal classes without bias.

When I got rushed in for an EMCS, even though I was off my head on gas and air, I had to sign a consent form for the surgery which listed all the possible dangers.

Why do they not do the same for a forceps intervention seeing as it also comes with lots of dangers? Do they not need informed consent for something potentially so traumatic?

I think the issue there is that an instrumental delivery isn't a 'natural delivery' either. I think they promote vaginal delivery but overlook the fact that an instrumental delivery is actually almost surgery in some cases. Ok the baby is still coming out that way but there's nothing natural about it.
I think the attempt to bring the c section rates down is probably putting more pressure on for instrumental deliveries maybe in cases where sections would be more appropriate.

Please don't think I'm belittling anyone who has had an instrumental delivery by saying it wasn't a natural delivery. It's not meant in that way. It's more meant that I don't believe it's helpful for health professionals to class it as a natural delivery because it actually belittles what mums go through in a vaginal delivery, especially when intervention is needed and damage is done.

My friend ended up with a ventouse delivery because they thought the heart rate was dipping even though she had gone quickly and baby was coming of his own accord. Turns out the machine was faulty!

rubyred: I agree. Once you do your research there is a whole host of information out there about the risks of instrumental delivery and the merits of c-section versus forceps etc. A lot of it is very eye-opening and almost nothing that I read was mentioned in NCT classes or antenatal generally. The natural birth ideal is always presented as the norm for vaginal delivery: no complications, no major tears, no pelvic floor / continence issues (as long as you do those exercises!). In reality, there are a whole host of complications that are possible that are rarely talked about. The only place I've seen this talked about openly is here on MN where there was (maybe still is?) a thread for women going through repair surgery for major pelvic floor and continence issues. Vaginal delivery does NOT always equal complication-free, 'natural' birth.

Also agree that this is s hidden issue because it doesn't impact on hospital stats or costs related to maternal health. Women suffering long term pain and incontinence issues do not appear in the stats that matter for obstetric units.

The most damaging and hurtful angle on this to me is the natural birth ideology, this idea that all women can 'achieve' a drug-free, complications-free birth when really it is the luck of the draw, beyond our control.

There are a lot of posts and to think that I thought I was alone when I was miserable about my son's birth, the way it went and how it left me, thinking I didn't deserve to be this f*cked up over it all.

My issue is that they cut me and my mum at the time knew I didn't want any intervention so she denied it for me, but they insisted my son needed to be born then and there. Why I don't know and whether they could've just left me to birth him by myself without complications I don't know. I would rather have torn naturally than be cut by someone I had never met before. My son was not a big baby at all which makes me doubt their actions. It was a pretty fcking isolating experience, no communication from the midwives at all, they told me jack sht about what was going on!

It's a good point about c-sections targets should not come at the price of forceps damaged women. Not all vaginal births are equal (or better than a c-section).

A few years ago a friend of mine was lamenting her c-section - the birth happening in theatre, lots of people, the anaesthetist fussing over her, the sense of passivity as someone else got the baby out of her, the helplessness, the age it took for the stitches to be done, the not being able to hold her baby, the long recovery.

I gently pointed out to her that my vaginal delivery had been exactly all of those things too, just my stitches were a lot harder to keep clean in a different place to hers.

And if you ask me, an episiotomy is pretty barbaric and lacks the finesse of a surgeon's scalpel. They use shears, ffs. A woman is cut open like a sack of rice.

She felt a failure and disappointed. I felt more angry at my misfortune, but not a failure. I was an amazing creature while I was labouring. I was strong in the face of agony, brave when things started to go wrong, determined when I needed to be. I was also able to look after my newborn despite having had 72 hours of labour, a pph, being unable to walk or even get out of bed. I was a hot mess of snot and tears on day three, of course, but I don't feel ashamed for that. I had all sorts of complications and was kept in hospital for a week and met a conveyor belt of doctors, registrars and consultants trying to figure out the damage (I was as incontinent as my newborn and no one knew why).

Occasionally we get a thread here on MN where someone touts the "vaginal birth is best" line or the "I birthed my baby through my vagina and that makes me awesome" and I feel my blood pressure rise. Equally I hear the "well a c-section is much harder. It's major surgery donchaknow", and my blood pressure rises, too. I feel like I got the worst of BOTH worlds.

I had first dc by EMCS due to undetected breech. I then had subsequent dcs by ELCS. DC2 resulted in a spinal headache which I would not wish on my worst enemy. Dc3 was fine, the best of the lot. I have a CS overhang (a gunt) but that's all. No tears or prolapses or any of the hideous things so many women suffer.

What an odd thing to say pinguina. Having had a traumatic first delivery myself am I not allowed to express a different opinion? My DC was in distress and removed via forceps while I was under GA. recovery was slow and painful but I did recover. I would still not want to go back in time and insist on a c section instead. The OP seems to suggest this would have been preferable - not for me it wouldn't. Individual cases should not form the basis of policy. The OP complains she was not informed of the risks of a vb. I was shocked at the way my first vb went so badly wrong but thats because I was so convinced it would be fine, not because I didn't know what the risks were.

I think we're all frigging amazing - giving birth is a bloody amazing thing to achieve no matter how you do it! I think we all deserve mega kudos for making and delivering a baby!

In response to "my baby is fine" comments... My baby was NOT fine. He had a major bleed to left cranial lobe. He has partial paralysis to the right side of his body and learning difficulties. If I had a crystal ball of course I would have opted for EC. I didn't and neither did the midwives etc. My baby is alive (he's ten now) and every day he brings joy. 50 years ago one of us would be dead. It was horrible and I'd rather black it out but I look at the positives. to l had a severe prolapse but the psychological scars are worse. I would never risk another pregnancy after the trauma me and DS went through.

I found out about this through research/friends' experiences and because I had an independent midwife who was very hot on giving you all the information and letting you make your own mind up. Therefore, when DD got stuck, I insisted on an EMCS, but it was just luck that I got it really, as DD was in distress so they wanted to get her out quickly (although I had also briefed DH what to say/do if the situation arose). I had no issues with the EMCS and recovered quickly. It makes me that women suffer because of poor communication and cost pressures and that rehab is so patchy.

At least if MN talked about it people would be more aware.

OP

I meant to add birth cranial bleeds (resulting in cerebral palsy) are more common with forceps delivered babies. It was the first thing the consultant paediatrician writes on the notes when your baby is transferred from scbu to paediatrics. Sadly.

I kind of get where you are coming from. If there were to be a mumsnet campaign it should be about informed choices in childbirth.

Although I'm medically qualified, and thought I knew the right questions to ask I still went into my first labour completely unprepared for what would happen. I'd done hypnobirthing and was aiming for a natural vaginal delivery. But I had a very poorly positioned back to back baby, and went into labour without any engagement. Intense continuous pain led to an epidural, then me being stuck in my back and baby not making his way down, result was a forceps delivery and 3rd deg tear. I was shell shocked by the whole thing but felt just plain relieved that we both survived. My relief turned to anger when, doing a little research, I found that this was extremely predictable! The position, lack of engagement and being my first made an instrumental delivery, or an emergency section extremely likely. So, why do we not give women this information during pregnancy and weigh up their specific risks in early labour and let them make informed choices?

My second showed me how easily it goes when the baby is in the right position (which I'd worked on achieving using the spinning babies website). Rapid vaginal delivery with manageable pain.

But my other bugbear is that in both instances with 3rd deg tears, why aren't women being sutured carefully in theatre by the most qualified to do so (gynae surgeons)? We just get stitched up, variably, by whichever midwife happens to be handy as though it were just some minor cosmetic would. No recognition of the significance of the task upon furture continence, sexual activity or general health. It's one of the last great bastions of casual misogyny in the western world, that we aren't worth enough to get actual surgeons repairing these woulds.

*cosmetic wound.

OP. I had a similar birth and I'm also still suffering the after effects 3 years later.

Captain- I am shocked about that too. Mine was only second but the mw and registrar were both very clear it wasn't a mw job. He checked me and I got the impression the consultant might be called. Stitching needs more respect.

4th degree tear after a forceps assault delivery. Induction, back to back first baby, stop and start contractions, epidural that only worked partially... All textbook (I know that now). No I wasn't informed of the risks. No I didn't consent. In fact my birth plan stated clearly, pointlessly, no forceps. There was no emergency, they were just "following the protocol" and wouldn't let me push anymore. I will never forget how violent it all was. Still I have healed relatively well.

Yes I wish they'd gone for a section instead. Had an elcs with dc2 and it was a blooming walk in the park.

Gosh it's so hard to remember all this

Also, women should be fixed -up by qualified surgeons if they are ripped to shreds. Not just a few stitches by a MW or nurse.

BabyGanoush in the case of a forceps delivery, the woman is always sutured by the surgeon who performed the delivery, not just "a few stitches" by whomever is hanging around. I have never seen a case where this didn't happen. (Also, nurses don't suture.)

But my other bugbear is that in both instances with 3rd deg tears, why aren't women being sutured carefully in theatre by the most qualified to do so (gynae surgeons)? We just get stitched up, variably, by whichever midwife happens to be handy as though it were just some minor cosmetic would.

Again, misinformation or misunderstanding here. Midwives do not suture third degree tears. Not ever. We are not trained or qualified to do so. Third degree tears are always sutured in theatre under a spinal by a surgeon. The only case where this wouldn't happen is if the person who did the delivery misdiagnosed the tear as second degree and passed it onto someone else to suture.

Hang on Bue - you've said "the woman is always sutured by the surgeon who performed the delivery" regarding forceps. I had forceps but they were performed by the registrar on delivery ward, not a surgeon. Do you mean forceps in theatre by a surgeon would be sutured by that surgeon?