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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Should we think of birth as normal, or as dangerous?

 

A few weeks ago I gave a talk to a group of health professionals about the impact of a traumatic birth on relationships. At the end of the talk, an obstetrician in the audience took me gently to task for using the phrase “when birth goes wrong”: problems such as retained placenta or postpartum haemorrhage were so commonplace, she said, that they were a routine part of the experience, rather than a sign of something going wrong. She added: “The day she gives birth is – apart from the day she’s born – the most dangerous day of a woman’s life.”

It was a striking comment, and one I’ve been thinking about ever since. There is an alternative view of childbirth, which is that it’s a “normal, physiological process”. It’s a view that’s endorsed by the Royal College of Midwives (RCM), and some NHS trusts have appointed midwives to act as “normal birth leads”, helping women to “achieve” a normal birth. Many midwives believes that an important part of their job is to support women to give birth “normally” – that is, without a caesarean section or intervention such as forceps or Ventouse. Proponents of normal childbirth would argue that an over-cautious approach to risk is in itself damaging, leading to unnecessary interventions that result in a more traumatic experience for mother and baby.

Childbirth is possibly unique amongst medical specialisms in that it is dominated by two professional groups who to some extent have competing views of what the job is about. Obstetricians see risk and danger; their job is to make sure that mother and baby come out of the process alive and, ideally, unharmed. Midwives see their job as supporting women to do what their bodies are designed to do: women have, after all, given birth for the entirety of human existence, and are therefore quite capable of doing so today.

You can see, of course, that both arguments have merit. Lots of women do have straightforward births, with minimal intervention. In the past, certainly, unnecessary medical intervention (the eagerness to induce labour, or speed it up artificially, or to give women episiotomies as a matter of routine, or to force them to give birth lying down) worked against the female body’s ability to do what it is designed to do, which is to push a baby out.

On the other hand, you can’t deny that, left to labour without intervention, things don’t always go according to plan: the baby is in an awkward position, or the birth canal is too narrow, or the baby’s shoulder gets stuck on the way out, or the placenta is retained and the woman haemorrhages.

Are women’s expectations too high? Or too low?

I hesitate to suggest there should be a happy medium, because I don’t know what a happy medium would look like. But what bothers me about all this is that women are caught in the middle of two competing narratives. Obstetricians at the talk I gave expressed the view that the reason some women find birth traumatic is that their expectations are too high: they think that they can give birth “normally”, with minimum intervention, and are then disappointed to find that that isn’t the case.

But where does that expectation come from? Not, surely, from an innate sense of hubris or over-confidence, but from imbibing the message that it’s possible to achieve a normal, problem-free childbirth by taking a positive mental attitude: if you believe in your own body’s capacity to give birth, the argument goes, then you’re much more likely to have the birth you want than if you approach it fearfully.

Thus are women caught in a Catch-22: going into birth in the hope and expectation that your experience will be “normal” means that you are more likely to be traumatised when things don’t work out as planned; going into birth with an awareness of all the potential problems and risks mean potentially that your own feelings of fear and anxiety will make the experience more difficult and painful.

And women get the blame. Women’s choices are mocked: they are “too posh to push”, for example, or they are “selfish” for wanting a home birth, free of intervention. They are naïve or silly for imagining they can give birth naturally; or they are wasting the NHS’s money by demanding a planned caesarean. A woman’s place is in the wrong, James Thurber once wrote: and if we’re talking about giving birth, then Thurber hit the nail squarely on the head.