Why forceps can be dangerous

 

Forceps deliveries and Ventouse deliveries are significantly more dangerous for both mother and baby than a caesarean section, according to new research published in the Canadian Medical Association Journal. The risk of severe complications to the baby is 80% higher.

The study looked at 187,234 births. The main finding was that “among women with dystocia and prolonged second stage of labour, midpelvic operative vaginal delivery was associated with higher rates of severe perinatal morbidity and mortality compared with cesarean delivery.” To put it more simply, more babies died or were injured during an instrumental delivery than during a caesarean section. Although the study found that maternal mortality was no higher during an instrumental delivery, “rates of obstetric trauma” (this refers mainly to tearing) were higher.

This matters because in the UK, as in many other countries, there are moves to reduce the caesarean section rate, partly because caesareans are expensive, and partly because of the risks attached to abdominal surgery. The caesarean rate in this country is one in four, which many experts think is too high – and as a result, many hospitals now have “normal birth” targets.

The findings of the new research suggest that this drive is misguided. There have been a number of well-publicised cases over the past five years of babies dying after the mother was refused a caesarean section.

But there is a risk to the mother too. The Australian obstetrician Hans Peter Dietz has been outspoken about the target to reduce caesarean section rates in New South Wales, which has resulted in a huge increase in forceps deliveries, but also far more cases of women with severe pelvic floor and anal sphincter damage – something that can be absolutely devastating for women. Dr Dietz found that 81% of women who had forceps deliveries suffered internal damage.

Obviously there are caveats. A response to the research article by obstetrician Nicholas Pairaudeau argues that the decision to use or not use forceps should depend on factors such as the size of the woman’s pelvis and the positioning of the baby. He writes: “Even though I have used forceps for nearly 50 years I have, in my own practice, reduced many of the complications quoted, by careful selection of the patient, forceps, and type of pelvis. C-section is not a simple option in many cases, and is associated with major complications too.”

The question of risk in childbirth is never a simple one: often it’s a case of having to decide which is the lesser of two risky options. The worry is, however, that by setting a target to reduce caesareans, hospitals then become focused on the process rather than outcomes. A caesarean in itself is not a bad outcome: a dead or injured mother or baby is. Doctors’ decisions should be based entirely on whether they will lead to a healthy mother and baby – not on they meet an arbitrary external target.

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The terrible consequences of a difficult birth

An Australian study has made some troubling findings about the problems that can arise from a difficult vaginal birth.

In an earlier post, I quoted Professor Hans Dietz, who believes that the “increasing push towards natural birth is having the unintended consequence that more women are having longer, more difficult labour”.

Dietz and his colleague Elizabeth Skinner have published qualitative research on the psychological consequences of a traumatic vaginal birth. They spoke to 40 first-time mothers who had suffered physical damage to their pelvic floor or anal sphincter muscles while giving birth.

From the interviews with the women, they identified certain key themes, including conflicting advice from clinicians before, during and after birth; nil postnatal assessment of injuries; dismissive reactions from clinicians to the women’s injuries; and experience of PTSD symptoms.

The authors write: “Major somatic [physical] maternal trauma after vaginal birth is one of the main causes of pelvic floor dysfunction, and it also seems to be associated with significant psychological morbidity up to and including postpartum post-traumatic stress disorder”.

For those of us who have heard many women’s stories of traumatic deliveries, this is all too familiar. It’s particularly concerning that women often receive conflicting advice from midwives and obstetricians; along with my colleagues at the Birth Trauma Association, I firmly believe that midwives and obstetricians should share some of their training, so that they can agree on best practice when it comes to supporting a woman during birth and assessing risk. Poor working relationships between midwives and obstetricians was one of the problems that led to the deaths of one mother and 11 babies, according to the Morecambe Bay investigation report.

But we have also heard, many times, stories from women who have said that their doctors don’t take their injuries seriously enough, and we are only too aware that a traumatic birth experience that results in physical damage can cause PTSD – something that clinicians are still unaware of. The consequences for women can be both profound and long-lasting. The research authors say: “Mothers after traumatic birth are likely to have a reduced quality of life due to both psychological and somatic morbidity.”

And it’s impossible to disagree with their conclusion: “There is a great need to learn how to better help women who have sustained these injuries by acknowledging their concerns and providing diagnostic and therapeutic services. This is unlikely to occur unless health practitioners learn how to diagnose maternal birth trauma properly and account for women’s perceptions and needs following traumatic vaginal childbirth.”