Assisted delivery vs EMCS

[MeadowHay]

I'm only 30 weeks atm but in the last few days the fact that I am actually pregnant and I will have to give birth in the not-so-distant future has just hit me like a ton of bricks. I have an anxiety disorder anyway so I am trying to be as informed as possible but not get too stressed out about it all. I am finding my lack of knowledge making me more anxious though.

I have been terrified about the prospect of an EMCS ever since a particularly horrific episode of One Born Every Minute where a lady was having an EMCS and her anasethetic suddenly started to wear off in the middle of the procedure, she was screaming and they put her to sleep straight away ofc. It might sound silly but that has never left me! But also there's the fact that recovery afterwards tends to longer/harder I guess (I know it's different for everyone ofc).

I know basically nothing about assisted deliveries. Obviously everyone wants to avoid an assisted delivery if possible but I always thought if the obstetrician recommends it then it must be for the best. However there seems to be a particular connection between vaginal/anal trauma and assisted deliveries and now I'm wondering whether I'd rather actually just go straight to a CS if I was in that position? I keep reading awful stories about people having long-term problems with vaginal/urethral/anal function and it's making me really anxious. However on the other hand I know that if it was an EMCS the damage might already be done by then anyway...

Anyone got any thoughts for me? There doesn't appear to be much research on outcomes or much guidance available online for me to think about.

I absolutely didn't want an assisted delivery and that was all my birth plan said but I was having double incontinence issues during pregnancy which is unusual. I had an emcs in the end due to unexpectedly big baby who couldn't descend ( which also explained the above problems). The emcs was fine they were very careful to make sure I was numb,and it was a calm straight forward operation, the recovery from the actual c section wasn't too bad I drove after two weeks, avoided lifting heavy items for a few months and tight jeans etc hurt the scar for a few months. I don't have any problems with bladder and bowels now, I probably will when I'm older but I can live with that.
There are some Cochrane reviews on forceps deliveries and c sections if you google.

I had an assisted delivery (forceps) with my first and it was very traumatic. I suffered ptsd as a result. I am doubly incontinent as a result. When I went back to work 12 months later I had still not recovered. It has taken me 6 years to dare to get pregnant again and I have elected a c section. I’m under know illusion that it is a walk in the park but if I’m going to get cut open I’d rather they cut my lower abdomen than my Fabio.

Hi @MeadowHay,

You're right, there is a correlation between instruments (particularly forceps) and anal sphincter injuries (OASI also called 3rd and 4th degree tears).
They are a natural risk of vaginal delivery. NHS choices give the following figures:
1% in spontaneous vaginal birth
up to 4% in ventouse delivery
and 8-12% in forceps delivery

www.nhs.uk/conditions/pregnancy-and-baby/ventouse-forceps-delivery/

These stats are general and do not take parity, age, BMI, baby size, pelvis size and other factors into account.

Again you're right that if the obstetrician recommends forceps for example, it is because it will be safer, particularly for your baby.
There needs to be a set of criteria met for obgyn to use instruments. These are explained here:
patient.info/doctor/delay-in-labour-and-instrumental-delivery

Unfortunately it is not always possible to avoid instruments. If you look at the table explaining the classification of forceps, if baby is low or at the outlet, forceps are safer than c-section (in this position, c-section carries risk of skull facture/death for baby and serious bladder injury for mum). Sometimes in mid-cavity position, there might be a choice between forceps or c-section. In high position c-section is safer.

I also see that avoiding an epidural is given as a way of minimising the risk of needing instruments but there's a small study that indicates this may no longer be right.
www.rcog.org.uk/en/news/study-suggests-epidural-does-not-slow-second-stage-of-labour/

An epidural might in fact reduce the risk of severe tearing
fn.bmj.com/content/96/Suppl_1/Fa75.2?utm_source=TrendMD&utm_medium=cpc&utm_campaign=Arch_Dis_Child_TrendMD-0

Sorry for the long answer but I hope it answers your questions.

Thanks. I feel quite stupid that I didn't really think about birth that or do any research into it before we decided to try and conceive, and now I feel a bit trapped and very anxious about it all. I don't really want an epidural either as I don't like the idea of feeling numbness in my legs and not being able to be mobile etc. Basically it all just sounds awful and scary.

There's good evidence that having a birth partner/continuous support who is not a member of staff (I'm adding my personal recommendation here = but who has some experience of birth (ie a doula, a family member/friend who has given birth before)) increases your chances of a spontaneous delivery.
Personally I'd focus on "recruiting" that person.

If the anxiety is becoming too disruptive, I'd ask the GP if you could be referred to a perinatal mental health service. They are the best placed to help you with anxiety in pregnancy.

On the Pregnancy Talk, there might be some recommendations of support groups for anxiety in pregnancy. I'd ask there too. 😊

During pregnancy I always said that I did not want to have assisted delivery and would prefer to have a csection if it got that way. During labour obviously things wernt going to plan and I ended up in theatre. Baby was already way down in the birth canal so they recommended trying forceps and if that didn't work then they would move on. The forceps did work and I was traumatised after the birth. In physical shock for a week or two and put off having any more children.
I did suffer from a weakened pelvic floor and saw a physio from 6 months pp. It was horrendously weakened where I would wet myself but I could always smell wee in my underwear despite them being dry. By 10 months pp everything was back to normal and I've had no problems since. I'm also wanted to try for another baby soon but anxious about a 2nd birth! I won't let it stop me having another baby but I think I would say no to having forceps again!

I think that maybe your anxiety is making you focus on the negative outcomes only. Most women do not have either an assisted delivery OR an EMCS.
NCT stats say that around 13% of women have an EMCS (and not all are that dramatic - mine was classed as an EMCS but happened very early on in labour), and around 6.8% of births have forceps assistance. This means that over 4 out of 5 women have neither.

You can never guarantee any type of delivery, but you can strongly maximise your chances of a good one by continuing you exercise and do (or start) your pelvic floor exercises, and I cannot recommend hypnobirthing enough! I was very nervous second time around as it was a VBAC and a large baby while I am petite, the exercises I'd learnt massively helped me. 30 weeks is a perfect time to start too! Congratulations x

No advice from me, just support and saying I know how you feel as I'm going through the same thing.

I'm very anxious about getting a terrible birth injury and my highest priorities are avoiding forceps and an emcs. I was an enormous baby myself, ruining my mums body forever on my way out, so I'm sure my dc will be as well. So I've booked in for an elcs. I'll let you know how it goes!

I'm yet to give birth and hope I'm not being naive in my advice as I have never had any health anxiety issues (and know friends who do particularly in pregnancy so you have my full empathy) however I have stocked up up the hypnobirthing books and other 'positive birth books' and am attempting to flood my brain with these stories in order to keep calm with whatever birth decides to throw my way and so far I have built up a really resilient confident approach to my birth. Best of luck

Hypnobirthing and stuff has never really appealed to me as I've never really got one with breathing/relaxation/hypnotherapy stuff in the past. I don't mean to sound flippant as I know that kind of thing can be really helpful for people but it's just never really helped my anxiety or suited me. I think partly because I am autistic maybe. It's difficult to explain.

I will have a think about everything. I'm ok most the time then I just start thinking about it and getting really anxious and worked up and having a cry and I still have weeks and weeks to go and I'm worried it will just get worse. So need to find a way to tackle it all and be more positive . I am seeing the midwife next week so I will mention it to her and see if she suggests anything. DH is great but already getting a bit fed up of me and says I am worrying too much etc and should just try and distract myself and things which I understand but it's a fine line between being informed and like ruminating over worst case scenarios. Because equally if I don't have a clue what is going on then that makes me more anxious too!

I am doing pelvic floor exercises but only about once a day and I think you're meant to do them like 3 times a day or something aren't you? I just never remember to do it more often. I am a size 10 and my baby seems to be measuring consistently around 50th percentile so not massive.

I had a forceps delivery 4 months ago and I am still suffering as a result. I suffered a second degree tear and had an episiotomy neither healed right due to an infection along with the fact it wasnt properly repaired. I had to fight for weeks to even get them to acknowledge the fact it was all coming open. I was fobbed off and told to go home and accept it. I paid to see a brilliant consultant who specialises in these issues and I have recently had re constructive surgery. I have spent weeks in bed unable to walk, I am a single mum and had to have loads of help from my mum. I honestly couldnt have managed without her. Shes been amazing and so far the repair is looking good. I am lucky i had some savings or I dread to think of the mess Id have been left with along with being in constant pain forever, unable to have sex, toilet issues and sitting on a donught cushion. Sorry for TMI but I am determind that women should know the truth before signing that form. Ive known women have far worse issues than me. In many ways I have been lucky. I wrote on my hospital notes and had it signed by a consultant that I wouldnt not accept forceps under and circumstances. I begged and begged for a c section after 2 days in labour following an induction and over 2 hrs of the pushing stage. I was refused, they told me the baby was too low down, but that if forceps failed they would try a c section afterwards. This made no sense plus im very slim and my baby was very large and I had gestational diabeties. I later found out that my son was at the highest point where forceps are even legal. I was lied to. A cm higher and it would have been illegal to perform that delivery. They want to keep c section rates down. I admit i caved in under duress and exhaustion and signed the consent form before being wheeled into the operating theatre. It was very very traumatic and my son ended up in NCU with breathing difficulties as a result. I am in the process of formally complaining to the hospital. I think forceps are barbaric and should be banned. Definity refuse forceps. No matter what they will do a c section if you say no as there will be no other choicr but you will have to fight hard for it.

Thanks user. As terrifying as your post is, I am grateful for you sharing your experience. I'm so sorry you had such a horrible experience. As I have an anxiety disorder anyway, I don't think I can really advocate for myself in a stressful situation so I really need to have a clear birth plan in writing but also clear with my DH so he can help be an advocate for me. He is studying to be a Physician Associate at the moment which is also useful as he has some medical background and can learn about this kind of thing good and can evaluate evidence sources good too. Two of his aunts had forceps deliveries and neither had another child after (first child for one and second child for the other). Not saying that is the reason but one aunt in particular seemed quite distressed even mentioning it, the one who gave birth in the last few years.

I have reserved the two books my library has, one on positive birth and the other on hypnobirthing. I really need to try anything to get a grip on my anxiety as it's getting out of control.

Also since I started this thread my situation seems to have changed - I saw the MW and my fundal height measurement suddenly shot up to 95th percentile on my growth chart, and I was only 0.3 under the sugars limit for GD! So now I'm even more anxious about the prospect of having a large baby that I can't birth!

I wish every day that I'd been given a C Section. Nearly 5 years on from my forceps delivery I'm in huge amounts of pain everyday, I can't live my love from how I want to and it's soooooo hard. I'm probably the exception to the rule, but it was horrendous at the time and is still horrendous now

I had a forceps delivery six months ago. DS heart rate dropped and he needed to be delivered straight away. However, happy to report that there's has been no long standing damage. Yes I had quite a few stitches and was sore for a couple of weeks and my pelvic floor still isn't quite what it was before childbirth but other than that I'm fine and so is DS. Not wanting to negate PPs experiences but wanted to add a positive story to give you some balance.

MeadowHay I dont want to scare you but definitly ask to see a consultant about whether an elective c section is best for you. I was nervous as I knew my baby was big. I wasnt confident about the birth. My sons head measured on the 98th centile on growth scans and his weight at 37 weeks was estimated at 8 pounds 13oz and as I had Gestational Diabeties I had an Induction despite my fears. I regret this as my diabeties wasnt detected until week 37 although for some time I was measuring very large and was having growth scans for other issues that showed my son to be between 95th and 98th centile with all measurments, my midwife was useless and I didnt have time to see a consultant or consider my options . He was born weighing 9 pounds 5oz two weeks before the due date which isnt enourmous but I am very slim in comparison. There was no way I would ever have been able to push him out with my build, but you might be different. Many women have big babies all the time with no problems. If you see a consultant they will be able to properly asses whether it is likley you will be able to birth your baby naturally or not and talk through your options. I actually originally wanted a home birth but I had a very difficult pregnancy and was very unwell throughout. I knew it wasnt an option and in the end I wanted a c section but it all left too late plus the hospital care where I live is terrible. There is only one main hospital in Cornwall and its very over stretched. I am sure you will be fine whatever you decide. I wish you the best of luck.

From Positive Vibe

"Again you're right that if the obstetrician recommends forceps for example, it is because it will be safer, particularly for your baby. "

I would just correct that to state it MAY be safer. I was, undoubtedly, coerced into a forceps delivery to keep the hospital CS stats low (midwife introduced the Consultant as doing this the following day "here's the man who keeps our CS rates down"). I had high (rotational) forceps which you go on to state mean that a CS is actually safer.

I suffered faecal incontinence and DD is permanently scarred on her face.

My birth plan stated I wanted to go straight to CS if an instrumental delivery was necessary. I was utterly exhausted and wracked with pain as they persuaded me to have the instruments. I'm still fucking furious and distraught over 8 years later. It also strained my relationship with my husband.

Thanks Sally I appreciate you sharing your story too.

I think what I'm thinking at present is, wait and see what my growth chart says when I see the midwife next Tuesday (not this one coming) for my 34 week appointment. If it's still 90th percentile or above then ask for referral to consultant to discuss ELCS - not dead set on it at this point but would want to discuss, and ask for growth scan if midwife doesn't offer one. DH is coming with me to help advocate for me. Also ask for referral to perinatal mental health team as my anxiety over birth is getting out of control. I'm having nightmares about it now and everything. If baby is measuring below 90th percentile then I will still speak to the midwife about possibility of a growth scan because that would mean it had not grown as much as it should have?

If I'm satisfied that baby is unlikely to be really huge then I will proceed down vaginal birth route - as that is what I'd prefer out of the two really if things are going ok, I'm definitely not set on a section. But then I think I would not consent to instrumental delivery in labour and would prefer a section unless baby is in the lowest part of the birth canal and there is some huge urgency to get it out. And again I'm hoping my DH can help me advocate for myself.

Be weary of being coherced into a forceps delivery though. You can write it in your birth plan but still if the baby needs to come out quickly then really chances are that you will have a forceps delivery regardless of what is in your birth plan or if you sign consent forms. Just a thought.

Yeah, I mean if it was an emergency then there's not really much of an option though is there . Or if anaesthetist not available for section. But other than that will just try have to try and be really insistent. My husband is studying to be a Physician Associate so I think his medical background might help a bit too in advocating for me.

Up to 50% of forceps deliveries can result in something called levator ani avulsion. It’s where your pelvic floor muscles are torn from your pubic bone. It can’t be repaired and it’s a devastating injury. Professor Peter Dietz is one of the world specialists on this injury. Forceps should be outlawed.

Amen to that

Hi everyone,
I'm not trying to be awkward but if baby is low in the birth canal, instruments are safer for the baby than a c-section. It's not a good scenario. Clearly the risk of injury to mum is high but there's a chance of getting baby out relatively safely whereas a c-section at that point carries really high risks to baby.
Mid-cavity deliveries are a point of contention. I don't know enough to know why sometimes instruments are recommended and other times c-section is preferred.

Table 1 on page 4 does not give the risks involved but explains the position in birth canal when instruments are indicated.
www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg26/

Hi guys, just wanted to comment quickly as I had rotational forceps delivery 7 weeks ago and have been absolutely fine afterwards, yes was in a bit of pain for a week or two after but nothing that couldn't be controlled with some paracetamol, I appreciate i and my little girl are very lucky to come out of it so well, I just wanted to post as it's not always a traumatic outcome. I hope you get to have the birth that you want op x

Hypnobirthing was great for me, as I was terrified of all things birth. It wasn’t hypnotising or anything like that, just helped me to see birth in a different light, and feel more confident in my choices.

I had an EMCS in the end and it was fine. I’m sure hypnobirthing helped me - I felt calm throughout and look back on it all quite fondly, rather than feeling traumatised by the whole thing.