Anyone refused forceps and insisted on cs

[Floozie66]

After reading all the horror stories fro forceps i have come to the conclusion that a lot wonen are left with more gynae problems following forceps which are often left untreated by the nhs compared to problems following cs. Therefore if push comes to shove i would elect cs over forceps delivery - mw had also advised that baby can be pushed back up to facilatare this. Jusy wondering if anyone had a major battle with the obstetrician regarding this choice or was pushed into forceps delivery by saying it was too late for a cs

My friend had a forceps used during a c section too. Her baby had the forceps mark on her cheek and her mother kept saying 'I don't understand, you had a c section?' But it does happen sometimes!

My DD was back to back and got stuck due to not fully turning and tipping her head. They tried the ventouse twice (by this point they'd moved me to theatre so obviously were not massively optimistic about success!) and I then had a EMCS which first involved her being pushed back up so they could make the incision
My notes made it very clear that I didn't mind how I gave birth but that I did not want them to use forceps at at point. (As a side note, my recovery from the CS was fine).

I agree with an earlier posters advice - be clear with your boundaries for the birth - if that is you will refuse forceps then make it clear to anyone and everyone necessary.

Good luck!

I had EMCS with DC2 after I refused consent for forceps. But they wanted to use the 'mid cavity' forceps to turn the baby. I think they had to pull him back up a bit although he was stuck quite high up IYSWIM. I found this CS much harder recovery wise than I did with DC1 (also an EMCS but calm and at an earlier stage) but that that might have been for many other reasons. DS was absolutely fine... although my 8lb baby had a head that was off the scale (to the extend we've had lots of investigations by doctors worried about brain abnormalities before they decided that his head is just the way he is!) so I can't imagine what might have happened if they had persevered with the forceps.

It was quite a 'fight' to insist on the CS and I was made to feel terrible by the doctor in charge. I was already in theatre as they wanted me in theatre before I even started pushing as things were not going well. But even though I had it in my 'approved' birth plan and had DH fighting my corner I had to get very 'assertive' and refuse consent for forceps- not easy as I wasn't in the best state after 80+ hours of contractions and a full night of interventions...

But afterwards I think every midwife on the Ward who had heard what had happened accepted that I had probably done the right thing. But this was due to my circumstances of the mid cavity turning. But of course that's with hindsight.

I can completely understand your feelings about forceps but I do know other people who've had them and been ok. And the recovery from the last CS was very hard. At the end of the day they cannot do a forceps without your consent and if you refuse consent you may force them to do CS.

It massively depends on what the situation is, and specifically, how low your baby is.

Doctors gauge this by a theoretical line between two bony prominences inside your pelvis (felt during a vaginal examination) - the "ischial spines". If your baby is distressed and needs delivery, even if you're fully dilated, it will be a CS if the top of the head is above this level.

If the head is well below this level, it is well down in the pelvis and should be delivered vaginally (I.e. ventouse or forceps if natural isn't happening or baby distressed) because it will be a traumatic, difficult, dangerous caesarean, for you and the baby, with a big risk of bladder damage and serious blood loss for you and skull fracture for your baby. If your midwife thinks that in this situation, the baby's head can simply be pushed up to make a caesarean easy, and that this would be in any way a good idea just to avoid forceps, I'm afraid she's clueless. We do ask someone (usually an experienced midwife because of the risk) to push up on the baby's head, but only because otherwise we may not be able to deliver the baby, and the push-up itself comes with a very real risk of skull fracture. This is not something I would recommend you ever choose.

The in-between grey area is trickier and your preference may come in to play here. If the baby's head is essentially at the level of the spines (and it's not always an easy assessment to make), there is a choice to be made - do they attempt a forceps delivery, or go for caesarean? You may be surprised to hear that obstetricians will tend to be pretty conservative and go for a CS if they are in much doubt - because there is not much worse than failing to deliver with forceps and needing to do a CS anyway.

If they examine you in theatre and choose a caesarean, then yes, they may give the baby's head a little nudge upwards just to raise it a centimetre or so in the pelvis and make the CS that bit easier. But this is a different kettle of fish to the emergency push-up done when a baby low in the pelvis ends up delivered by CS.

If not done for fetal distress, the usual other reason is a malposition - the baby is back to back or looking sideways. Again, if this has halted the labour before the baby crosses that imaginary line, it will be a caesarean. If it has already crossed that line, trying to turn the baby and then deliver vaginally would be better. If it's hovering around the line, it will be the obstetrician's opinion on the safest method, but your preferences may well sway them too.

Unfortunately, no one can tell if things are going down the route of needing forceps, so we can't do a CS "before it's too late". You need to be fully dilated before forceps can consider being used, and once you are, it will all be about the position and station (level within the pelvis) of your baby, which will be very specific to each woman's individual situation.

There's forceps and forceps. Have you researched the three different types?

Labour and delivery is very dependant on luck and positioning - partucularly with a first baby.

Personally, I think knif you have thoroughly researched the position using objective evidence (i.e. not anecdotal), the best thing for everyone is for you to opt for an elective section. That will let you retain a degree of control and absolute consent that there won't be possible in many labours.

I was offered ventouse, then obstetrician started waving forceps about. I asked where exactly he thought he was going with those (have you seen the size of them?!), so they went for the ventouse after all. Pretty rubbish communication. My advice would be to do your research,listen to your instincts, and don't be afraid to speak up for yourself.

Thanks for clearing that up DoctorMonty

Thanks dr monty 😊 it helps to know exactly why they might reccommend one over the other and what the safest option is at the time

Doctormonty thank you for giving a drs perspective, but if a csection is usually more dangerous than forceps, why are forceps rarely used in the USA ?surely its more a matter of opinion, and if the baby is low down in a good position why not use ventouse, which is usually much better for maternal health?

DoctorMonty:

I wish doctors would be more willing (in general) to explain stuff properly like this!

Trifleorbust: Thanks - but you can see how long it took me to explain all of that, and I was trying to be as brief as possible! If you're utterly exhausted or the baby is potentially distressed, you can see how hard (read: impossible) it is to gain or give true "informed consent" in such situations. Which is why I personally would want this info before the situation arises.

Stairway: U.K. and U.S. practice is very different, so I really can't comment with any real authority. For instance, it seems almost routine to induce women, and site an epidural before they're even contracting! They also perform (or certainly were until recently) midline episiotomies which seems a bit silly to me.

My guess would be a combination of bailing out a lot earlier (I suspect almost any deviation from normal results in the recommendation for a caesarean), and the idea of forceps being unpleasant and - yes, admittedly - being historically associated with birth injuries.

Ventouse cups are more traumatic for babies, and also more prone to failure (e.g. popping off due to loss of suction). Each doctor will know what they feel comfortable using, but kiwi cups are often ideal if the baby is really low and won't need much help but the woman is exhausted, or if it the head is slightly malpositioned and just needs some gentle tweaking/encouragement to rotate and then comes easily.

I think that there's an idea that because suction seems like quite a "soft" thing compared to metal forceps, they're softer/kinder somehow. Not really true. You can do a lot of damage with a Ventouse cup if you don't use it properly, and a well-performed forcep delivery can be a beautiful thing (believe it or not!).

DoctorMonty: Of course! I doubt I would have retained the info whilst pushing. That said, there is a lot of 'we'll cross that bridge when we come to it' directed at patients.

In most of the world except UK (for example France, Scandinavian countries) the preferred method of assisted delivery is ventouse. Moreover it seems that the UK is also trying to decrease the rate of forceps deliveries in favor of ventouse.

The reason for these big and costly policy changes is of course is not that "forceps seem soft" () like a previous poster said or any such subjective reasoning. It is because research has shown that they do cause more birth injuries to mothers. In untrained hands they are also more likely to cause birth injury to children.

Here is a survey www.ncbi.nlm.nih.gov/pmc/articles/PMC420176.

The reason why UK is lagging behind in the switch to vacuum is in my opinion that UK is generally prone to hold longer onto traditions (and forceps were English invention!). I am only half-joking here...The immediate reason which you would note if you read maternity wards performance reviews is that English doctors are untrained in the use of vacuum and apparently not enough is done to change this despite the general policy guidance to switch to forceps (this is what the reports say). Another reason is that litigation is much less likely in the UK (I wonder personally if it is because you are also less likely to win in court...)

I think the patients deserve to know the truth about different delivery methods. Research does show that vacuum is safer for mother and baby. There are also ways to deliver a low head by c section when vacuum fails, arguably safer for the mother than trial of forceps. Lots of sound research on this subject as well.

Lcat: If you know how to deliver a low head by caesarean in a way that is safer and less traumatic than a forceps delivery, you should write a book and make a million. It is one of the most fear-inducing procedures in obstetrics.

There is a relatively new device, the fetal pillow, that safely elevates the fetal head by a few centimetres to make it easier (the lower segment will still be very thin and the bladder very high). This looks promising in trials and is being rolled out in many units. But the whole reason they developed it and sell it is because everyone acknowledges how difficult and dangerous it can be.

There is no question it is more difficult than straightforward section. It still doesn't mean that forceps will be preferable. The fact is forceps are just no longer routinely used in many hospitals outside the uk, in particular in the us. This leaves c-section as the only option if vacuum fails.

One of the methods to deliver impacted head that appears to compare favorably with others is reverse breech extraction. I am not sure if that's what is usually used in the UK. But clearly each individual doctor should and would do what he is best trained to do, and if it is forceps she will use forceps. So all this is of little concrete use to patients unless there is a change in how new doctors are trained.

Just to add: I would be really interested in seeing the research you're referring to if you would be able to link to it?

The research that I'm aware of suggests forceps are indeed more traumatic for the mother but are also more likely to succeed. Given that a failed instrumental followed by a further instrument or caesarean is going to be more traumatic than either ventouse or forceps used on their own, there is definitely still a place for them IMHO (and in the opinion of the 2010 Cochrane Review authors).

In terms of fetal injury, whilst facial forcep marks are common/unavoidable, these fade pretty quickly (usually within a few days). Retinal haemorrhages, subgaleal haemorrhages and cephalhaematomas are more common with ventouse, and these are much more unpleasant than some temporary facial bruising. Babies don't have much blood in them and they can lose quite a lot into a cephalhaematoma, which is why jaundice is more common in babies delivered by ventouse too.

In terms of length of neonatal unit stay, cord pH etc, there will obviously be a bias towards ventouse looking favourable because in situations of particular concern about a baby (eg. the monitoring looks particularly worrying), they will choose the quickest and surest mode of delivery, which is forceps.

All in all, certainly in light of the Cochrane review (which admittedly is 7 years old now), I don't think a blanket statement that "vacuum is safer for baby" is necessarily true, and this is would be backed up by anecdotal/personal experience (never seen anything beyond forcep marks with forceps, but have seen some nasty cephalhaematomas). But happy to be corrected if there's new evidence I'm not aware of.

This recent study seems to suggest forceps, ventouse and second stage CS are largely equivalent (but with more celphalhaematomas with ventouse, as expected) www.ncbi.nlm.nih.gov/pubmed/28222428. It's a pre-publication release though so not had a thorough look. This five year follow up of forceps vs. ventouse suggests equivalence too. www.ncbi.nlm.nih.gov/pubmed/25488084

Finally, UK doctors most certainly are trained in ventouse deliveries. It is a requirement to progress beyond the first stage of training.

I had a birth plan in which the only thing said 'I don't want rotational forceps, I would rather have a c section'

They took me to theatre for rotational forceps and luckily enough I was together enough to protest. While I protested, the baby moved down the birth canal and they used low forceps. My OH is a dr and was watching. I'm still not sure what would have happened if baby hadn't moved. It's such a vulnerable time for everyone.

When I had DS 20 years ago I wasn't asked what I wanted, all I was aware of was alarms going and a room full of people! A doctor saying we have to use forceps and not seeing my baby for ages after.
DS was very bruised, I was a mess, stitches etc but he was alive and I was ok. My plan just said please keep us both safe.

I'm surprised at anyone saying suction is not widely used in the UK. I knew many people who had this over 10 years ago. My understanding coming from the receiving end of a high dependancy birth (for myself rather than the baby) that they will do the quickest delivery route they can. And as someone who was on the receiving end of that choice having to be made I trusted that my Dr wanted to keep me and my baby alive...birth plans are one thing but sometimes there isn't a choice.

Never in a million years did I ever imagine having to defend my birth and the untold trauma it caused!
The ventouse was used. In fact the first obstetrician who came to use it seemed very confident my baby would be out quickly.
But it failed.
A more senior obstetrician was called in. He tried the ventouse again.
It failed.
A whole team of people came in and I was delivered by forceps.
Statistics for forceps do not show whether forceps are used first or whether they came after ventouse failure.
I only wish the trauma I suffered on my worst enemy but what was the alternative? A seriously injured or dead baby? Sometimes there's only a least worse choice to be made. I just wish there was more awareness about it.

We seem to agree that forceps cause more maternal trauma than vacuum. (This seems to be a consensus in the literature as well). Specifically, they cause more severe tears. The consequences of these tears are long lasting and often severely impact mothers quality of life.

There is no doubt that vacuum causes hematomas and forceps cause facial injuries, but in the absolute majority of cases both have no long lasting sequelae, unlike tears.

I also personally think that vacuum is more fool proof than forceps. A less experienced doctor, I imagine has more potential to do damage to the baby using forceps than vacuum, due to vacuum potential to transfer force being much less. I don't know of any systematic research corroborating that, although I am not alone in this opinion.

Very relevant to this thread: an article comparing forceps vs cesarean following unsuccessful vacuum attempt is www.ncbi.nlm.nih.gov/pubmed/17674268. There were (unsurprisingly) less severe tears but more bleeding after cesareans. Outcomes for babies were similar. Knowing this what do you chose as a doctor? As a patient? As a hospital with a spending budget to plan? Clearly the answers might be different.

Finally a review containing some more information on assisted delivery www.ncbi.nlm.nih.gov/pmc/articles/PMC3307924/#CR8

But for an individual patient what can you take out of all this information? The use of forceps is not unavoidable. There are many many hospitals in the world that won't due to their policy ever consider using forceps on you. However if your hospital does use forceps (in the UK they all do) it is very likely that you won't be able to refuse. This is because in a true emergency situation your doctor is best left to do what she is trained to do. If her protocol is vacuum-forceps-cesarean or even forceps-cesarean (because there is a difference in ""knowing how to use" and "using all the time") you don't really have a choice. You might try and refuse if the situation is more relaxed, but there is no guarantee. The only way to prevent this situation is to not deliver in this hospital or deliver by c section.

Your hospital forceps delivery rates are listed in care reports. It is a good place to look if you want to get a feel on what your hospital policy is. Some hospitals have a higher than average forceps delivery rates (and yes, believe it or not, the reasons cited by staff are that they don't feel comfortable with vacuum )

In reality there isn't always a choice is there. The OP is an experienced mother and I'm sure she understands that sometimes we don't have choices: I had a baby at home with no issue, no tears no stitching fabulous. I have also had a very medicine led delivery whereby if I wasn't in hospital and very quickly delivered I would have died. Birth plans are fine in their place if everything is going to plan and I totally agree no one would choose forceps delivery, but they do have their place especially if you or your baby is in a critical condition. I know though that it's very difficult to have an open mind though when you're worried about the after effects. What I think we do very badly in this country is after care for terrible tears and botched repairs. I certainly think this should be talked about more as women are being expected to put up with some terrible side effects of these very invasive procedures. Just don't put too much credence on the idea that they can push your baby back up and give you a cs, I imagine it's possible on occasion but not consistently.

We use fetal pillows at work to disimpact a low head. It's not the miracle that the reps would have us believe. It's a bit fiddly to use and takes time that we don't always have.

Mine was an EMCS due to cord prolapse so my baby was well on his way but they pulled him back up and out. Not recommended apparently, i think you might have to insist on that at the point things go wrong you want a C sec. If this isn't your first baby, trust me at the point you or the baby is in danger you'll do whatever is safest whether that's forceps or section. My birth was very traumatic but at the end of the day we are safe and sound because i did what the medical staff advised me to do.

I've just had my consultant appointment (in which I booked in for an elcs). I asked if I was going for a natural birth, could I refuse forceps and he said that they go for whatever option is best at the time for safe delivery - basically I think they would make it very difficult to refuse at that point. This was one of the reasons I decided on a c section as I know a few people who have had horrific forceps recovery.