Jill Raleigh Fischer, a nurse, wrote about her experience with forceps and incontinence on The Skeptical OB Facebook page in response to my piece Incontinence: the traumatic result of vaginal birth that dare not speak its name. Jill gave me permission to share it on the blog. She was motivated to share her experience after reading a DONA international article “ACOG to OBs: Consider Operative Vaginal Delivery to Reduce Cesareans,” and notes that operative vaginal delivery has the highest risk of pelvic floor damage and subsequent incontinence.
I am a sample of one and my forceps baby is almost 41 years old… born in the heyday of forceps deliveries. Do I want any and all measures to be used to save the life of a mother and her baby ~ absolutely. Do I think “operative vaginal delivery” should be used to reduce cesareans ~ hell no!
That said, my son’s mid-forceps delivery was performed by a perfectly competent obstetrician in a perfectly fine hospital. No one has been sued.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]Try asking some women how forceps delivery worked out for them.[/pullquote]
I went into labor at 40 weeks gestation with a SROM (spontaneous rupture of membranes) and progressed normally for a first labor. That is until the second stage of labor (pushing). After three hours of trying very hard to push an occiput posterior baby out, a forceps delivery was recommended. A spinal anesthetic was administered and forceps applied.
My entire body moved down the table with the pulling and tugging applied to my son’s tiny head and body. With gratitude from all that is within me, he arrived healthy and whole and suffered no more than a bruise to his beautiful face. He had no lingering problems from his traumatic entry into the world.
However, forceps delivery is an incredibly invasive procedure and can and does result in trauma to babies and to their mothers’ bodies. This consequence appears to be grossly under reported or even recognized. The above New Yorker article cites the historical lack of use of evidence based practices in obstetrics. Perhaps that has changed, but no one has asked how I have fared since my forceps encounter.
My first experience was intense perineal pain. Sitting for a month plus was very difficult. On the plus side, I was able to have 3 more children with natural, vaginal deliveries. Would I have traded being able to have fewer children had I undergone a cesarean section the first time and having 4 with the pelvic difficulties I have had? That is a loaded question I can’t answer since I adore all of my children.
I had complete urinary incontinence immediately following my son’s forceps delivery. I was horribly embarrassed. This improved but persisted as a problem. By the time my youngest child was 4 (and the first one was 10) I was experiencing pelvic prolapse. I underwent a hysterectomy and bladder suspension. 4 years after that I underwent an A & P repair. The damaged tissues between the vagina and the urinary tract and between the vagina and the end of the digestive system needed to be repaired to improve function of both systems and decrease urinary incontinence.
With the passage of time, aging and gravity, inherited quality of tissue, and the emerging thought that these procedures are not what should be done, I found myself needing a pelvic reconstruction at age 55. Seems old ~ so what? It’s not old when it is you this is happening to. Again, I was fortunate to work with an exceptional surgeon and had insurance to assist me in obtaining good care. But, there is no putting it back the way it was no matter what kind of deliveries you had. With my history, I had even less chance than that.
Still, the evidence seems to suggest that the kind of damage I have suffered is less common following cesarean section deliveries. Did anyone ask how it went for me? Did they ask anyone? Any real studies done that support using operative vaginal deliveries in lieu of cesarean section deliveries?
I am not writing about a few tugs on a vacuum, though this should be done with the utmost thought, skill, and care. I am writing about a violent procedure and to say that there is no reason any woman should again endure a forceps delivery merely done to avoid a c-section. It may look cost effective and that it reduces pain and suffering. I am telling you that from my experience, it costs plenty of money, plenty of suffering and it costs women world wide their dignity.
So, try asking some women how forceps delivery worked out for them. And, women… fight to retain control of your bodies, your healthcare and your birth process!
Thank you for sharing your story, Jill Raleigh Fischer. Before my forceps assisted delivery a few years ago and subsequent Pelvic Floor issues, I had no idea how prevalent pelvic floor disorders are in women. I also had no idea that forceps assisted deliveries were a common cause. Before I knew the damage that been done to my insides, I was so appreciative that my doctor had done all he could to prevent a dreaded c-section. You see, I had completely bought into the idea that a c-section was one of the worst outcomes possible. It’s been a very painful (physically and emotionally) awakening, to realize just how wrong I was. I have often wished since my son was born that a c-section had been performed. I believe I very likely may have been spared some of the lingering physical and mental trauma I have endured. My son did not appear to have any negative effects, but then, he can’t tell me how physically and psychologically awful the experience must have been for him. It hurts my heart to think about it.
In 1982, at 34 weeks with my second child, the membranes prematurely ruptured (as had happened at 37 weeks with my first). I spent the next ten days in hospital, on a drip containing antibiotics and medication to prevent labour.
I had daily visits from obstetricians to check progress.
A month before the due date, he somersaulted in the middle of the night, re-rupturing the membranes and triggering labour. The midwife refused to believe me that he had turned – of course, no-one knew then that I have a connective tissue disorder that makes such movements easy (EDS) – and insisted that he was presenting well, as the obstetrician had written in my notes. She even insisted that she could feel the baby’s nose (the mind boggles).
Well, because of this and my very fast labours (thanks, EDS, again) we had barely settled into the delivery room when I needed to pee; I sat on the bed pan, had a sudden urge to push, moved forward onto my hands and knees, and his feet came out. Bright blue, and definitely feet. Not a nose in sight.
No time for niceties such as pain relief – everyone went into Fast Walk Mode, an obstetrician armed with forceps appeared, someone else found stirrups and set them up, my husband (who had walked into the hospital just as the alarms went off and saw the sudden change in staff perambulations to not-quite-running) helped the midwife to flip me onto my back and then all I remember is pain. Horrible, horrible pain, as the obstetrician saved my baby’s life at the expense of my private parts.
My husband, who was leaning across me, holding my shoulders down, said he was deaf in his left ear for a week after that.
Do I regret that delivery? Well, if there had been such a thing as an ultrasound machine available, his position would have been obvious and I’m pretty sure that I would have been happy to have a Cæsarian section. Under the circumstances, though, it was the only option that could, and did, save both our lives. He got to grow up. And he got married this week.
I went on to have two more pregnancies, both vaginal deliveries, even the twins. The stretchy tissues due to EDS that caused a lot of pregnancy problems also meant that I suffered less long-term damage than I might otherwise have done, but I have been partially doubly incontinent ever since; and it has got worse with age. I know women in their eighties with better bladder control than I had in my forties, and in my late fifties it is now the case that I am very grateful for modern aids in that department. Of course, the EDS also means that surgery isn’t an option – the risk of making things worse is higher than the possibility of making them better.
That anyone – let alone anyone with medical experience – is suggesting that a forceps delivery is better than CS boggles my mind; given the choice, I would have opted for the latter, and I don’t do well with surgery. I can only think that those suggesting it see women as ambulatory incubators. Mustn’t damage the incubator, it could hold LOTS more future babies! Just rip apart and tape back together the ancillary tubing; its integrity isn’t vital to the running of the incubator itself, and who cares what effect it has on the incubator when it doesn’t contain a baby? Snarl.
I live in the UK, so I knew my forceps risk was higher than the US. It was the one thing I didn’t want, so of course it happened. But given the risks, the baby needed to get out then. I wouldn’t want it again, but all said I was back to normal by my 6 week check. I had some issues for the first month or so, not with an incontinence though, just uncomfortable feeling of needing to go. I did a lot of pelvic floor stuff years before getting pregnant, but I just consider myself lucky. Of course, being in the UK means they have more practise with forceps, so you are more likely to have someone skilled. What happened to that South American guy and his forceps replacement?
I think part of the problem and one reason why there are so many disparate anecdotes, is that the safety and efficacy of forceps and vacuum are both very dependent on operator ability and the exact situation. That makes it all too easy for the wrong choice to be made. This doesn’t mean that forceps are bad or vacuum is bad or c-sections are bad, but it does mean that they all have definite risks and problems associated with them. Especially if the particular OB involved doesn’t have the best skills in a particular technique. I don’t know that there’s anything to do about this except for OBs to be honest (especially with themselves) about their strengths and weaknesses and to discuss risks and benefits as fully and clearly as possible with patients. Sometimes, though, it’s going to come down to what’s available and practical in an emergency.
I don’t know. Maybe uterine replicators or teleporting babies out will become practical at some point in the future. Until then we’re all going to be playing the odds, even those who have completely normal unassisted deliveries. And none of the potential answers are totally wrong or totally right.
The biggest difference is that c-sections are NOT very dependent on the skills of the doctor. It’s a simple operation that is easy to teach and, for OBs, easy to perform. Have you read this article? It’s fascinating:
http://www.newyorker.com/magazine/2006/10/09/the-score
In my experience, skill does vary with OBs as far as surgery goes. One OB who recently left our hospital was not a skilled surgeon, and I would not have gone to him if I needed a section. Another one of our doc’s has a tendency for her patients to bleed quite a bit. I’m not a surgeon, so I can’t say how simple the surgery is or not, but I definitely think some do better than others.
Yeah, I’m sure you’re right–it’s just common sense. But apparently far fewer docs are below par in doing c-sections than in using forceps. I read a fascinating article about this (mainly about Virginia Apgar, but also about this) in the New Yorker recently:
http://www.newyorker.com/magazine/2006/10/09/the-score
I read the link and found it very interesting. I didn’t know that forceps required such great skill and ‘feel.’ Thanks for posting.
I would agree here. The doctor who did my Cesarean had a reputation for being a wildly excellent surgeon. I was told this by multiple people at the hospital & my surgical recovery was amazing & you can barely see my cesarean mark. I have to believe some of that was skill.
There may be less interoperator variability with CS than with forceps but, having assisted mutiple different OB’s on CS as a resident, I can tell you there are definitely ones who are much better than others. In fact, when I found out who was on call when I needed my CS, I (and my family doc) were so upset about the idea of him doing my CS that we called my regular OB backup and she agreed to come in on a Saturday morning to do it because we all knew just how bad a surgeon this guy is. I am so thankful she came in too because my section ended up being complicated and I know it would not have gone well if the on call OB had done it.
Many women make an effort to seek out an obstetrician with a low c-section rate. I’ve always felt that, given the fairly high probability of a c-section at any given birth, it’s better to seek out one with a high c-section rate.
Thanks for sharing this article. Very interesting and well-written.
I’m really considering retreating from commenting here anymore, even though I’ve gotten a lot out of it. And despite that this site helped me immensely in my postpartum period, when I was absolutely surrounded by NCB people blaming me for everything that went wrong in my childbirth. Obstetricians saved our lives, and obstetricians told me none of it was my fault.
Because it’s one thing to have some NCB person tell me how much I suck. It’s
another thing for a regular OB commenter to lecture me, about how I am
the wrongest person ever, for being all right with ventouse – and specifically with the ventouse that my baby
received. The obstetricians who were attending my birth counselled me as to why I was a “good candidate” for ventouse, but whatever. The doctors who were right there in front of me, couldn’t have possibly had any clue what they were talking about. I had some unique anatomical issues when I was in labor, that definitely affected their decision. But the important thing is, ventouse is bad and I should feel bad.
I think I see the comment you mean. Honestly don’t take the replies so personally. I think that comment was a more general frustration than directed at you. The baby is in you, there is risk to staying in and there is risk to every single way of getting out. You did the right thing in my mind, that some don’t do, you trusted that your doctor had expertise and experience. What other truly sane choice is there? And it turned out well. Nothing to feel bad about and I really don’t think anyone meant to make you feel bad. Ventouse isn’t bad, cesareans aren’t bad, forceps aren’t bad, vaginal delivery isn’t bad… they are all going to be the absolute best choice in some situations and they are all going to be someone’s horror story. I don’t think the OB meant you were the wrongest person ever or you should feel bad. Hugs and I hope my scary link wasn’t part of it.
Definitely go with what your doctors said. They were there, they obviously used it for a good reason/s, and they saved your lives. I’m sorry that you’ve been left feeling crappy thanks to a comment here.
The doctor literally in front of you is the person you need to trust, not some Monday morning quarterback, even if the quarterback is Joe Montana.
Edit to add: Anything else will just drive you crazy.
Fallow, I’m so sorry this has been so upsetting for you.
My comment was simply a reply to the last comment in the thread, not directed at you specifically, but at all the misinformation in the thread – and floating around this comment section in general – about vacuum/ventouse delivery and forceps. Meant to clarify the facts of different methods of delivery and the associated considerations/risks. Obviously you had a ventouse delivery that went well, and I have absolutely no opinion on the care you received except to be glad that everything went well. As has correctly been said, I wasn’t there. I’m sorry that I clicked “reply” to you specifically instead of the initial post up the thread and left you feeling attacked – not my intention at all.
Not entirely sure of the details. The OB used forceps — he called for the preemie ones, and he explained that he wasn’t pulling out the baby, but just turning the baby while I pushed. From my perspective it looked like he was mixing a salad. Then he stepped away, the CNM took over, and then the head was born, and then they told me to push and I basically rocketed my son at the poor CNM!
So, outlet forceps? In any case, I struggled with incontinence for the first week, a draggy feeling for the next four months, and rare stress incontinence for the first year; everything feels permanently in the wrong place but with a lot of core exercises I can manage the symptoms. Not sure whether it was the hours of pushing or the forceps.
Pregnant again now and hoping the second kid fits easily through the path its brother blazed…
Unfortunately, this post has brought out all the Anecdata (anecdotes misrepresented as evidence or data), exactly what we accuse the pseudoscience contingent of using. Forceps are associated with a slight increase in pelvic floor problems, and are dangerous in unskilled hands, it’s true. But multiple cesarean sections are associated with life-threatening placenta accreta and percreta. There is no perfect solution, but as an obstetrician in a tertiary centre, I have seen both, including a woman who would have died at her cesarean hysterectomy without the 30+ units of blood and the 5 surgeons (including myself) and two anesthetists who spent over 6 hours working on her. (It was only her 3rd cesarean section.)
Some posters here, like Rosalind Dalefield, have been vilified for speaking truth that other posters don’t want to hear, and I am ashamed of the responses to her.
I think Dr. Amy’s point is that vaginal birth is not the be-all and end-all. Agree, there are sometimes worse things than a cesarean section. But that doesn’t mean that operative vaginal delivery should be lost from modern obstetrics – it is often the safest way to deliver, both for this pregnancy and future ones.
What are these truths that Rosalind Dalefield has spoken that other posters don’t want to hear? Nobody has vilified her. If she had come on here and said simply “Hey let’s not forget that most forceps deliveries, like mine, end very well for both baby and mother and can prevent a CS which is very important to decrease accreta” nobody would have had a problem. Instead she vilifies vacuum deliveries and asserts that since pelvic floor injuries can happen during NSVD too, that it doesn’t matter that they happen more often in forceps births, and forceps mothers who have sustained catastrophic injuries should shut up about it. She was rightly criticized for both of those arguments.
Of course accreta is a huge problem. Your own near-miss anecdata is horrific. How could it not be seared into your brain? But how could mythsayer’s anecdata be any less seared into her’s? Her cousin’s face got smashed in.
Dr. Tuteur’s point is simply this: If we are going to push operative vaginal births to reduce the CS rate, there are going to be increased rates of other bad stuff. It’s nice that Rosalind had a technically excellent OB with lots of forceps experience. Presumably your patients are equally lucky. But what about the ones that aren’t?
“Dr. Tuteur’s point is simply this: If we are going to push operative vaginal births to reduce the CS rate, there are going to be increased rates of other bad stuff… But what about the ones that aren’t?”
I absolutely agree with you! My concern is the follow up comments that make factually inaccurate claims about forceps (e.g. brain damage, which is actually higher with vacuum and cesarean section babies). And when skilled forceps aren’t available, then again you are absolutely correct, women need prompt access to cesarean section.
As for Rosalind, she’s been subjected to comments like, “Why are you being such a jerk?”, “My mind is a bit boggled that you were willing to argue.. in favor of forceps.”, etc. I haven’t been commenting much recently because of what I perceive as a loss of some of the civility that I’ve always cherished in this community. I’m disheartened, and miss the humbling level of candour and analytical thought that I’ve become accustomed to from the extremely intelligent and thoughtful group of regular commenters here.
“As for Rosalind, she’s been subjected to comments like, “Why are you being such a jerk?”,”
Posters have simply been responding to Rosalind with the same tone that she has been using herself. When I disagreed with her, she said “You’re not very good at stats are you?”. She says that when a mother allows an OB to use a vaccum on her baby she is making an “inhuman” choice. Rosalind has indeed been a jerk, and calling her out on it isn’t unreasonable.
Okay, okay, I’ve been schooled. You’ve made excellent points, and made them very diplomatically. 🙂 Thank you.
She is entitled to argue in favour of what she wants, as far as I am concerned. She just isn’t entitled to say that a nurse’s experience wasn’t what she said it was, implying that the woman in question hid details of her own medical history so she could accuse Saint Forceps.
She also isn’t entitled to insist that forceps is always preferable to “inhumane” vacuum. I consider myself pretty human, thankyouverymuch.
“factually inaccurate claims about forceps (e.g. brain damage, which is actually higher with vacuum and cesarean section babies”
CS is not a higher neurologic risk than a complicated vaginal birth. The Mayo study showed that the lowest risk of learning disorders was with planned CS. Sure, in the case of a baby way down in the birth canal, yes pushing it up to do a CS would be a higher neurologic risk than getting it out from below with forceps. But for a CS done early, that’s less risk. And women deserve to know that.
Absolutely true. I didn’t want to get into the nitpicky points, but you’re right, they deserve clarification.
But by the time your choices become vacuum/forceps/cesarean section, then women need to know that cesarean section is probably not better for baby’s brain and may be worse for a variety of reasons (difficulties with disimpaction of an impacted head and time delay until patient prepped and ready for CS are probably the two biggest ones).
“But by the time your choices become vacuum/forceps/cesarean section, then women need to know that cesarean section is probably not better for baby’s brain”
Oh for sure. But that brings us back to Dr. Tuteur’s initial point: the question of whether we should push to lower the CS rate by planning on more operative vaginal deliveries.
The people who are promoting this policy are not talking about the occasional case of a labor that is progressing well, but where the baby unexpectedly shows distress late in the game and is too low to delivery by easy CS. In those cases the safest choice is almost always going to be operative vag delivery. As a mother, I would never say no.
No, what they are talking about is the promotion of a policy where women with *difficult/long/iffy* labors are not offered CS while the baby is still reasonably accessible, but are encouraged to (made to?) keep going with the TOL, with the knowledge that some of these borderline labors will inevitably evolve into situations where Mom is exhausted and baby is stuck, or baby is distressed by the long labor, and then the plan will be to “rescue” the situation with forceps.
Sure, maybe the powers that be have decided that OBs ought to intentionally let themselves get into situations where the safest way out is forceps. Maybe they have crunched the numbers and that’s the best policy for the population as a whole. But I would like to think that that decision could be between me and my OB, not between the OB and the government/governing body. I never wanted a large family. Cognitive function is important to me. My pelvic floor is important to me. It’s my body and my baby and it should be my choice.
If you have read all of Rosalind’s comments, she clearly has a complete lack of empathy for the poster and does not understand statistics. I called her a jerk because she was acting like one. I am not sorry for calling a spade a spade.
What you may be seeing as a loss of civility might just be a different perspective. I accept your assertion that you are very skilled with forceps and that they work well for you and cause few complications. However, I personally would never want a forceps delivery (or any operative delivery, for that matter), no matter how skilled the operator was. The risks to the baby and the increased risk of pelvic floor damage, not to mention a personal sense of abhorrence and terror about the procedure itself make a CS a much more appealing proposition, even with its attendant risks. Rosalind is free to discuss her own example and good outcome, and your insight as an experienced OB is valuable, but why can’t either of you accept that other women may have different but equally valid opinions informed by their own experiences or values?
I accept that you and other OBs use forceps with skill and care and that the outcomes are usually good, but I still want nothing to do with them. They have risks, just as CS have risks, and neither you or Rosalind are in a better position than I am to decide which risks are more acceptable to me.
I had a personal sense of abhorrence & terror about a Cesarean that was in part justified by witnessing my mother’s experience with 4 classical cesarean followed by adenomyosis & hysterectomy in short order, but it didn’t serve me very well when I needed a Cesarean. The idea that women can avoid vacuum & forceps just because they don’t like them is slightly more accurate than the idea that we can will our way out of Cesarean, but not much more.
Well, no kidding. The baby has to come out one of several undesirable ways. But individual women can avoid forceps and vacuum deliveries if they are offered and choose MRCS, and more generally forceps will be less likely if providers go to CS earlier and specifically avoid operative deliveries, either as a general practice or in individual cases as an effort to respect women’s wishes about delivery.
How do we know that Rosalind’s positive experience with forceps had anything to do with the OB’s forceps experience? Maybe it was one of those cases where it only required minimum competency?
“Maybe it was one of those cases where it only required minimum competency?”
Her first was a rotation. That’s no beginner’s move. Her second she describes as a “lift out”, by which I assume she means outlet forceps. Yes, that is easier.
Well, that’s easy, doctor’s competency these days is measured only by patient satistfaction. 😉
You’re right, I don’t want to hear Rosalind Dalefield’s bragging how great her forceps births were and what mother over other mothers (like my own) she is because she chose the human way to birth her babies, via forceps, because forceps is always preferable to vacuum. Those other mothers (like my own) who chose to behave inhumanely towards their babies!
She doesn’t say that forceps and vacuum have their place, like you do. She just says, “Long live the forceps”, admitting that she went to doctors who had vast experience with it but insisting that it’s always preferable to vacuum, supposedly even when other doctors weren’t as greatly experienced as her own.
Hmmm. Think I might have missed some of that zeal. Either way, I agree that excessive zest for one or the other (forceps or vacuum) is misplaced.
A personal point: I prefer forceps because they have a lower failure rate, but for women who are motivated to push well, if baby is too high up for a vacuum, then I use forceps but gently slide them off at crowning then have mom push, to decrease trauma to the pelvic outlet as the widest diameter of the head comes through. Tends to work extremely well.
Also in the interest of full disclosure I have to admit: when I myself was pregnant, my Ob and I had the “what-if” discussion, I decided I would prefer forceps if there was an emergency, and would prefer to avoid a vacuum if possible, but was happy for her to do whatever she thought was necessary in the moment. In the end I needed neither, but who are we kidding, my pelvic floor will still never be the same.
As decidedly non-medical person, I can only guess that if forceps was as great in every situation and the obvious, better choice Rosalind considers it, vacuum would not have been invented. I bet that when Bujold’s ideas of uterine replicators can be applied in life, they will because they’ll be better fit for some mothers.
On a personal note: when my father first saw me, he thought I was brain-damaged for sure. A huge head being squeezed in, then a decision to use vacuum was made but not implemented… The vacuum was out of order so the doctor started repairing it. More squeezing for the head before the vacuum could be applied, so it didn’t have much of a head-like form. Birth ain’t a walk in the park!
Maybe I was your labor nurse. I had a dad once pull me to the side of the room and ask with great gravity what was wrong with the baby’s head. Perfectly normal top of the wrinkled walnut but yes, birth is freakish looking to the uninitiated!
My own conversation went “If Dr. X or Dr. Y are on, I prefer forceps, but if it’s Dr. Q or Dr. Z, I hope they choose the vacuum, but I will let the doctor choose in the moment”.
There are *clear* differences in forceps skill among the OBs in my system.
This is SO true. We have one OB left at our hospital (I’m a nurse) that is a master at forceps- he makes it look incredibly easy. If I need them this time, I would be fine with him using them. But if it’s his partner on that day? Nope. Most doctors seem to be using vacuums only now, although pop-offs associated with them kind of scare me, just because I’ve seen the damage they can do to babies’ heads.
I appreciate this. It’s consistent with my experience and how I would feel as well. Mostly, what I can’t stand is people having the idea they are completely interchangeable when they are not. Subgaleal bleeds are very scary and I personally, would rather risk my own tissue. But as you say, it’s skill dependent and some situations call for one or the other. Plus, the whole situation is tense enough without the patient having misinformation influencing her choices.
Can I ask how you train to use the forceps and vaccuum? And do you need them often enough to stay in practice, or are there ‘refreshers’?
Read this:
http://www.newyorker.com/magazine/2006/10/09/the-score
Your points are well taken: CS is associated with risks, and more so as the number of sections for each woman increases. It’s natural that the more dramatic consequences are forefront in your mind and influence your decisions.
Please remember also that there are consequences that you don’t see. There is psychological trauma and long term physical damage to consider. The vaginal delivery may look like a crisis averted, but only if you don’t count the life-eroding effect of pelvic floor damage, depression, and the risks and difficulties of subsequent surgeries — not to mention the possible consequences for the baby. I was very much in a life-threatening situation after my child’s birth, but because it was depression it was not visible to any of my care providers, and no link was made to the mode of delivery.
Remember also that each woman is an individual and deserves to have some ownership over the decisions made, as she will be the one to live with the consequences. It makes no sense for a hcp to make a blanket decision to avoid CS to minimize risks in theoretical subsequent pregnancies at the expense of an individual’s pelvic floor or her baby’s safety. You apply that risk:benefit calculation to women with very different values and future plans, and in the end you will improve the odds for some, but at the expense of others who would have been better served with a CS.
I’m sure you and fifty-fifty recognize that you are in privileged positions in terms of being asked for your delivery preferences. Many women are never asked these kinds of questions; they are simply given the management that their provider decides to give them. This is unfortunate and inappropriate, as the complexity of decision means that it should be informed by the individual characteristics and values of the patient.
Absolute… but I also offer my patients choices and give a candid opinion. For a baby stuck up in the mid-cavity, I discuss risk/benefits of caesarean section vs forceps. For a baby low in the pelvis, I discuss forceps (I do the work, you have a more sore bum) or vacuum (you have to keep working really hard and I only add an extra 10%). I try very hard to understand the “context” that women are coming from, and for patients I’ve cared for prenatally, I often have a good idea of which way they’re leaning and can help them to decide. It all changes if the fetal heart rate is 60, of course, to a pretty quick, ‘I think we need to do a forceps delivery right now’ – in the same way in which I happily gave my own doctor the same discretion when I laboured
As for experience, I did well over 100 operative deliveries during my training, but even now, there are some difficult cases and tight squeezes that I won’t attempt because I’m concerned about safety and the risk of failure, even though I know the “old guys” would.
And your points about respecting maternal preference and maternal experience are excellent ones, I absolutely agree.
Talk about a high-risk pregnancy: Within the next few months, surgeons at the Cleveland Clinic expect to become the first in the U.S. to transplant a uterus into a woman who lacks one, so that she can become pregnant.
http://www.amazon.com/Fourth-Procedure-Novel-Medical-Suspense/dp/0345402308/ref=sr_1_1?ie=UTF8&qid=1447392212&sr=8-1&keywords=Fourth+procedure
My mom was permanently handicapped by her own forceps-assisted birth. It tore the membrane surrounding the spinal cord, causing fluid to leak in and put pressure on the spine. That’s one of the reasons I insisted on a c-section. Since no one can guarantee you that you won’t need forceps to deliver vaginally, the only way to eliminate the risk of forceps injury to my babies was to go with a c-section.
OUCH. Spinal tears are the worst. I speak from experience. My tear was caused by a fall that ruptured a cyst I had on my spine. I am very lucky that I was able to walk again after one week.
Ouch! Yikes! Glad you got better!
Thanks! Sometimes it’s good to find out just how much pain you can bear.
I had mild stress incontinence after my first forceps delivery, which was a rotation. It might have been the forceps but it could have been the partial displacement of my sacrum and/or the fracture of my coccyx, who knows. I got some vaginal weights and built up my pelvic floor muscles and it went away. No similar problems after my second forceps delivery, which was a lift-out. Both babies were too far down, by the time it was realized that I would need assistance to deliver, for a C-section to be done without significant risk of trauma to both mother and baby. I went on to have two more babies and I think I would be in a hell of a mess internally if I had had four C-sections.
Many women have some degree of urinary incontinence after perfectly normal deliveries with no assistance. Correlation does not prove causation.
“Correlation does not prove causation.”
That is a misuse of this saying if there ever was one. The following rates of pelvic floor problems are well established:
never pregnant< pre-labor CS< in labor CS< NSVD< forceps birth
It's not just some coincidence correlation.
At a population level that may be true, but at the individual level, which is what this woman is writing about (i.e. herself) it is still a fallacy to assume that her incontinence problems are due to her forceps delivery. You’re not very good at stats, are you?
You experienced several other things that could have caused trauma (sacrum displacement, etc.). She didn’t.
Not that she told us about…
I’m sorry, could you explain what you think she was hiding and/or lying about? Otherwise, you’re casting aspersions in a baseless fashion.
“At a population level that may be true, but at the individual level, which is what this woman is writing about (i.e. herself) it is still a fallacy”
I agree what matters most is the population level. So why then do you go on and on about your own story? You’re not very good at stats, are you?
Because Dr Amy, and the author, are presenting this as a typical outcome of a forceps delivery.
“Because Dr Amy, and the author, are presenting this as a typical outcome of a forceps delivery.”
Not at all. What Dr. Tuteur is saying is that a forceps birth puts you at a much higher chance of having a severe pelvic floor injury and then Nurse Fischer shares in personal terms what such an injury was like for her. The point is that severe pelvic floor injuries are both life-altering and costly. If we, as a society, are going to push forceps births, we need to be very aware of the increase in severe pelvic floor outcomes that are invariably going to accompany this push.
” It is misleading to imply that a forceps delivery will lead to such problems.”
What is misleading is to imply that since it didn’t happen to you, then if it happens to someone else it must have been just a coincidence. That forceps lead to a significant increase in severe pelvic floor injuries is beyond debate. It is a fact that has been well established in the medical literature.
Why are you being such a jerk? Pelvic floor problems can have a huge impact on quality of life. I have fairly mild issues, but bowel urgency and occasional incontinence is pretty damned unpleasant. It’s nothing compared to what the author of this post went through. How can you not feel anything but sympathy for her and other women who have gone through this? It must be nice to have gotten lucky and not suffered any morbidity from forceps or vaginal delivery, but I fail to understand why you’re so damned smug about it.
My point is, it is impossible to say that it was the forceps delivery that caused her problems. Many women have forceps deliveries and don’t suffer as much as she did, and many women have unassisted deliveries and suffer bad urinary incontinence. My mother had stress incontinence all her life but it did not get worse as a result of childbirth.
It may not have been the forceps, per se, but it was almost certainly the decision to pursue a difficult vaginal delivery instead of doing a CS.
No one is suggesting that forceps deliveries are always terrible or that CS is always preferable. The piece is simply pointing out that forceps deliveries can have long-term negative consequences, that women should be informed about the possibilities, and that these consequences should be taken into account in decisions about limiting CS by increasing operative deliveries.
OT: Mom denied C-Section and baby dies: https://www.yahoo.com/parenting/family-seeks-answers-for-woman-denied-c-section-201501015.html
That’s so horrible. That poor baby, poor woman, poor family.
Ugh what a horrific story. That picture with baby on mother’s chest is just heartbreaking. Could he really have had his head born and body stuck for four whole hours though? I’m assuming that the aunt got something wrong in the timeline because I just can’t imagine a poor mother in a hospital with her baby’s head born but stuck for four whole hours. Ugh.
That poor little boy. Why would HCA employ a doctor with a history like that?
I’m not entirely convinced that this is a case of obstetrical incompetence: woman labours with baby less than 10 lbs, baby gets low enough that a vacuum-assisted delivery can be attempted (and for what it’s worth, I’m not a vacuum fan at all), and then there’s a significant shoulder dystocia resulting in asphyxia and death. This is absolutely tragic. And yet, every ACOG guideline would advise AGAINST routine induction for macrosomia (big baby). All of the more recent ACOG positions are advising for more allowance for long/slow labours in order to achieve vaginal birth when possible. So it’s possible that the delivering physician was utterly incompetent, but it’s certainly not a given.
The ACOG think tank has run these numbers over and over: the only way to prevent every shoulder dystocia causing asphyxia is to do cesarean sections more liberally – to the tune of well over 1500 cesarean sections to prevent one perinatal death, with resulting significant increases in morbidity ( clots/infections/etc) resulting from those surgeries. Unfortunately, as people we cling to this idea that if only, if only we do things *perfectly*, then we can have a perfect outcome every time. And the awful, unfair, unbearable truth is that there is absolutely no perfect or ideal solution – there are small and differing risks with each and every treatment or route chosen, and so overall one of the jobs of medicine is to try to minimize risks overall, on a population level.
It’s not an isolated event for Dr. Colman. The state medical
board charged her for failing to follow standard of care in multiple cases after she had bad outcomes for other shoulder dystocias resulting in two cases of Erb’s palsy,one newborn with seizures and at least one death. http://www.houstonpress.com/news/houston-doctor-accused-of-botching-dead-infants-delivery-7914866
You can read the complaint here [use style contains Colman to find her case] https://cis.soah.state.tx.us/dmwebbasic/tokweb27.ASP?WCI=tokwebmain&WCE=queryform&WCU=
The hospital is an HCA facility and they’ve been in trouble
before for the quality of care in their for-profit hospitals and for short staffing. Her medical school is ranked #133 out of 141. http://medical-schools.startclass.com/l/151/Meharry-Medical-College and she was not accepted to medical school the first time she applied, although the subpar school may not have been her first choice, just the one she got into. http://www.history.uh.edu/cph/tobearfruit/resources_bios_coleman.june.html
Absolutely true that this case needs careful scrutiny at M&M rounds and this doctor has some very difficult questions to answer – and she may not have adequate answers. But none of the facts you bring about her medical school or history means that she mismanaged this patient in this situation.
And M&M rounds bear no resemblance to a court, there is no “innocent til proven guilty”. Because of the importance of professional standards, it’s more like a firing line of “What the he!! were you doing? Why didn’t you do X? Y? Z?”
Hopefully they’ll actually look into it with an eye to improvement. The hospital has an awful reputation here.
Yikes. I think I live in a naive little bubble.
(I guess socialized medicine has is benefits up here.)
Yes, it’s pretty sucky down here in that regard. The company HCA has been hit with record fines for all kinds of fraud & crooked behavior.
http://www.nytimes.com/2000/12/15/business/hca-to-pay-95-million-in-fraud-case.html
Holy mary mother of…. Wow. Some of our politicians are pretty inept, but none bad enough to have to fork over almost 100 MILLION DOLLARS in criminal penalties. 🙁 Sorry you’re stuck with them.
Is it actually possible what the aunt says? That the baby’s head was born for four hours?
I wasn’t there so I don’t know, but that’s not really plausible. I think the more likely think is that she was pushing for four hours and during that time the nurse could see the top of the baby’s head in the vagina, but baby just wasn’t coming. Often nurses will coach women to push with encouragement, “I can see the baby’s head! You’re doing great! Keep going!” which could be interpreted as “the baby’s head was out”.
I’ve certainly seen women push for 3 hours where, with fingers in the vagina to help direct pushing, we could see the top of the head that whole time as it gradually (slowly) descended.
But if the baby’s head was out for more than about 5 minutes, most nurses would be calling in back-up OBs from far and wide to help resolve a critical shoulder dystocia. (At least, that’s what happens in our centre – at the 4 minute mark in a shoulder dystocia if there has been no progress, the call goes out for a second OB stat, just in case.) Even in the most lackadaisical centre I would expect the alarm to be sounded at the 10 or 15 minute mark if there was no baby coming.
Ahh okay, that makes more sense. Thanks!
There is a problem with rigidly applying population-based guidelines to individuals. Whether or not OBs should routinely advise for or against CS in any given circumstance depends entirely on what outcomes your are measuring and how you value them. And in a situation as complex as labor and delivery, there are so many factors that come into play– many of which are highly individual– that it doesn’t make sense to restrict one’s practice so that you ignore important individual factors over compliance with a general guideline.
A standard of care becomes absurd when it doesn’t take into account areas of gray or compelling personal characteristics. In this case, the baby was just under ten pounds. Was a difference of a few ounces significant enough to justify denying this woman and baby a CS? I suspect you’ll say yes, and justify it with ACOG guidelines, but the outcome argues against you.
Makes me want to cry. Especially the picture where she’s holding the baby. It is heartbreaking.
A close friend’s first child was nearly nine pounds at birth and she experienced shoulder dystocia with him. Her doctor used forceps because “or else she would need a c-section”. Because my friend absolutely didn’t want a c-section, she got forceps. As a result, her son’s clavicle was broken and in her words, she couldn’t use the bathroom properly for a good few weeks. Of course, she blamed being induced and having an epidural for all the problems related to his delivery, but I think had she had a 39-week induction (she was induced at 41 weeks), she could have avoided all of that.
May I clarify? I worry someone reading your post might think that forceps caused a broken clavicle.
Shoulder dystocia is delivery of the head, but the shoulders get stuck.
Shoulder dystocia is therefore only apparent after forceps have been used. It is not caused by forceps and it is not treated by forceps.
If a baby will not deliver you really do only have two options: operative vaginally delivery or CS.
If you don’t want a CS, operative delivery it is.
Sometimes the reason babies won’t easily deliver is because they are big, and if they are big their shoulders are more likely to get stuck.
If you have a shoulder dystocia all measures to release the baby quickly before they die of asphyxiation will be taken. You have less than 10 minutes to save the baby. Sometimes that means breaking a clavicle.
Because the alternative to a broken clavicle or brachial plexus injury is hypoxic brain damage or death.
I was going by what she told me and as it was, I didn’t know her until her son was preschool aged. Perhaps it wasn’t actual shoulder dystocia but he did get stuck somehow because of his size, forceps were used, and his clavicle got broken somewhere in the process. Maybe he was malpositioned.
Agree with Dr. Kitty. To further clarify, forceps only help to deliver the head and don’t go near the clavicles. Once the head is out, the forceps are removed. And then, if the shoulders don’t come (get stuck), then THAT is a shoulder dystocia. In the process of getting the shoulders out, a clavicle and be broken either on purpose or incidentally. But often the big baby is the reason for needing the forceps in the first place, if mom can’t push it out on her own.
Dr Kitty and CanDoc are saying what my OBs also said about shoulder dystocia and broken clavicles in newborns. It’s not impossible that your friend didn’t catch all the details of her birth, just because the event was so traumatic for her. It would be COMPLETELY understandable for her to not be 100% clear on the details of such a crappy situation.
I hesitate to ask, as my situation is much less severe than the posters, but what damage occurs from late pregnancy and baby positioning vs pushing? (I would assume that forceps do a lot more damage, but was curious following Dr. Amy’s first article.) I have some minor pelvic issues now that are likely to increase – but the actual pushing part was very straightforward with my kids. I think that have lasting damage from my darling child sitting directly on my pelvis. The separation in the third trimester huuuurt.
Are you having *pelvis* issues or pelvic floor issues? There is a big difference.
Pelvic floor
If you are talking about the pelvic floor what are you referring to when you talk about the separation in the 3rd tri that hurt?
Not diagnosed, but my guess is that I had something like pubic synthesis seperation during pregnancy-major splitting pain while walking, helped by some support- which went away after delivery. In the years since there’s been minor stress incontinence, possible abdominal separation, and a worsening of si joint dysfunction that I’ve always had. (Yeah, I know, go see doctor and probably get a pt referral.) Mostly curious about the mechanism for the ongoing issues!
So it sounds like your issues are not mainly pelvic floor then? The minor stress incontinence is, but the rectus diastasis, SI joint problem and pubic symphysis pain aren’t.
Not sure I’m answering your question correctly, but here’s a partial answer: Prolapse and fecal incontinence are increased in women who have had vaginal deliveries, but by age 40-50, all women who have been pregnant have about the same rate of urinary incontinence regardless of whether they birthed vaginally or via cesarean section. Cheery thought, isn’t it?
Well that’s extremely depressing.
Yes, yes it is. Lol.
Having worked in geriatrics, I can vouch for the fact that even women who never had children can experience incontinence. It can happen regardless of child bearing status.
There are many unavoidable and unpleasant consequences of being 50 that I would prefer not to experience from the age of 25.
You can’t ignore 4 deliveries in 6 years as a factor. Not one medical organization recommends that as acceptable spacing. She makes a valid point about forceps but that is not the source of all her pelvic floor issues. Thankfully the era of super short intervals is coming to a close.
“I had complete urinary incontinence immediately following my son’s forceps delivery.” Direct quote from the article. She also had severe pain for a month following that birth.
So her issues started immediately after the first delivery. Perhaps the repeat pregnancies and deliveries exacerbated things, but it’s clear that a significant amount of damage was done by the first delivery.
I actually don’t know the data on how patients are educated on spacing their deliveries. I think there is increased awareness that breastfeeding can be an unreliable method of contraception in the postpartum period. I do know a local hospital here that did a study on patient education about contraception options (any type) in the postpartum period. I don’t know the results of that very small study.
Are you sure that the “era of short intervals” is coming to a close? I waited until my mid thirties to start having children and when current uterine tenant is born my daughter will be 18 months old. I can hardly imagine I’m the only woman in her thirties who for career reasons, or whatever reason, decides to start late and then spaces her pregnancies closer because “time is running out.” In fact, I thought I had read somewhere (Up To Date maybe?) that this is one of two major demographic groups having short interpregnancy intervals and it is increasing.
She may have meant after c/s that it’s better to not have too short of an interval. That’s true but not always followed guideline.
Well, there is research that IPI of less than 6 months in particular is associated with poorer outcomes regardless of mode of delivery. My understanding though, is that a lot of research on this is confounded by the prevalence of single young teen mothers (already at higher risk for poorer outcomes due to their circumstances) who make up the other demographic group who have higher numbers of short IPI. AFAIK, there is not much research out there regarding older women who intend short IPI’s and whether their outcomes in particular are different.
Thanks did not know this.
Here’s one citation that mentions it:
http://www.ncbi.nlm.nih.gov/pubmed/23743455
It states that she was having major issues after her first birth, so while the other births may have exacerbated her condition, you can’t say that she would not have still had the same issues at some point. My mother has all the exact issues as this woman, but worse and needed reconstructive surgery at 47 and another at 58. I was the only child she ever gave birth to.
Ellen Mary, you are pulling this opinion out of your ass, as per usual. Her babies were hardly born at “super short intervals”. 4 births in 6 years means they were 2 years apart on average (6 yo, 4 yo, 2 yo, newborn).There is some limited evidence that waiting 18 months between pregnancies (so a spacing of 2.25 years between babies) is associated with decreased risk of premature birth of the next sibling, but there is no evidence that it improves pelvic floor outcomes.
Vaginal birth itself is a culprit. Urinary incontinence can be caused by carrying a pregnancy to term, but fecal incontinence is not. I certainly didn’t expect to develop that after delivering two small babies.
Is this really a big issue? Thinking about the indications for c-section and the 33% c-section rate, how much of that is due to c-sections being done in situations where forceps could be done?
All the pre-existing conditions don’t apply (breech, pre-eclampsia, previous-c-sections). And if you are talking about c-sections after TOL, how often is the baby in a position where forceps are an option?
This might not has as trivial effect as the 39 week rule or denying all MRCS, but it’s not going to have a big effect. OK, you cut c-sections by 10%, all the way down to … 30%? Yeah, that will make the NCBers happy, won’t it? And at what cost?
I think maybe the point is that we know some NCBers are advocating the use of forceps as a way to reduce the section rate. This has been specifically set out as a policy in Australia, I think just at regional level but still exceptionally worrying.
Yeah, but NCBers also support preventing c-sections before 39 weeks and MRCS. Even if implemented, neither of these would have a noticeable effect on the c-section rate.
NCBers just demonize all c-sections, they don’t care. It’s like anti-abortionists who are all concerned about eliminating third trimester abortions. Aside from the fact that it will not have a noticeable effect on the number of abortions carried out, it’s all about demonizing everything.
NCBers push the WHO 15% c-section rate. Even if we bought into that, you don’t get to a 15% c-section rate by using forceps instead a c-section. In fact, you don’t get anywhere close. You need to focus on the important factors, that lead to the most c-sections, not the trivial contributors.
Right, but I don’t think any of this means the push to reduce sections by increasing vaginal deliveries, as outlined by Lisa Barrett in Australia, isn’t relevant or worrying. This isn’t the exact document I was looking for, because the one that’s been mentioned on here before specifically says they aim to use instruments more as a consequence of using sections less, but it’s part of the same policy:
http://www0.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_045.pdf
I for one would certainly feel very frightened indeed by this were I unlucky enough to be delivering a baby in New South Wales.
Use of forceps can make a meaningful difference in CS rates under some models. For instance the original poster delivered at a time when mid and high forceps were permitted while VBACs typically were not because CS technique had not yet been perfected and so “once a CS, always a CS” because rupture rates were higher. Preventing that 1st CS could prevent many others, as was the case with the original poster.
Obstructed labor has always been a big driver of CS. An even slightly malpositioned baby can be the cause, and forceps can be the solution. Fetal distress is the other big driver. Mid or high forceps can deliver a baby very quickly that might otherwise be hours from delivery. And correct forceps use can reduce some of the fetal risks associated with breech.
But overall I agree with you. All of these models require *aggresive* use of forceps (i.e. mid and high forceps), and risky births like vaginal breech. Who in their right mind is willing to take these risks nowadays? Only those in very resource poor settings, or settings where many women want very large families.
“Who in their right mind is willing to take these risks nowadays? Only those in very resource poor settings, or settings where many women want very large families. ” Or, those of us in Canada, apparently.
Nobody that I know of does high forceps anymore (even in low resource settings) due to fetal risks, but mid cavity forceps deliveries, in capable hands, are as safe as low forceps deliveries and are excellent for the baby who is turned (looking) in the wrong direction. In my group practice, the male OBs (with their big paws) tend to do more forceps rotations, whereas we women (with our narrow/flat hands) tend to do more manual rotations (by hand), then apply forceps directly once we have baby looking the correct direction.
BUT in Canada the standard of care would dictate that mid-cavity forceps delivery should be done with a “double setup” – meaning we set up in the operating room for a cesarean section, so if there’s any concern that baby isn’t coming easily, anesthesia and the OR are all set up to transition immediately to a cesarean section.
(I tend to use forceps for the mid-cavity and for low/outlet deliveries where the mom is having difficulty pushing effectively, and vacuum if mom is pushing well but we need to speed up delivery a little, usually because baby is tired.)
” Or, those of us in Canada, apparently.”
No, not Canada either. Canada may be more liberal in its use of forceps that the US, but certainly does not have a model anything like was in place in the 1960’s (or that still exists in some developing countries). As you say, high forceps have been virtually eliminated, and mid forceps are restricted by standard of care to an OR setup.
To make a *big* dent in the CS rate by using more operative vaginal deliveries, we would have to go back to the old days.
I don’t even think forceps should be used in an semi-futile attempt to lower the caesarean section rate. I think they should be offered carefully in select circumstances, to women who would prefer to avoid a caesarean section. And there are some circumstances in which they are extremely helpful – low head but mom who just can’t push anymore. Vacuum not sufficiently effective with higher risk of failure, and the baby’s head so low that risk of severe hemorrhage with caesarean section is higher, just an easy little life to get baby under the pubic bone, then take the forceps off and let mom push the baby through the last little bit (thereby protecting the pelvic outlet by not dragging the engaged forceps through it). No desire to return to the days of the “vaginal caesarean section” (ie horrific operative vaginal delivery with terrible lacerations)… but important not to throw baby out with bathwater, either.
“important not to throw baby out with bathwater”
Absolutely. The original poster (Jill Raleigh Fischer) is very clear that forceps have their place. She is aware that her ability to have a larger family was likely a result of having a midforceps birth rather than a CS. Her goal didn’t seem to me to be to demonize forceps, but rather to point out that operative vaginal births can have real downsides and thus should never be considered a panacea. OBs need to be free to treat patients, not treat rates.
How much say does the woman have in this? If I were your patient, knowing that I was planning a small family, I would absolutely want you to go to CS well before there was any thought of forceps or manual rotations. On an individual level, the thought of having to go through a failed trial of forceps and then a CS would be totally undesirable, and yet it seems that your interpretation of the standard of care would force you to subject me and my baby to a number of unwanted procedures and risks.
How much consideration is given to the mother’s individual values and considerations? Is any thought given to the desirability of having a woman endure the trauma of both vaginal and CS delivery attempts? Or to the potential psychological consequences to the woman if she does not want an operative delivery, particularly for women who may have previously experienced sexual trauma?
I must admit this bugs me a little. I really agree that if it’s forceps vs safe c/s do the safe c/s. Don’t use them as a way to get better numbers that’s just idiotic, you want to treat patients (long term) not statistics. But I have always been a little wary of the trend toward vacuums being the safe alternative. Definitely safer for mom but not clearly safer for baby as many uneducated or inexperienced people think. Having worked in places where anesthesia is not in house there are occasions that an operative delivery can save a baby’s life. These are the situations that make me very glad I am not the one who has to decide which way to go, every choice has risk and no choice is great, but personally, If I lived in PoDunk USA at 3am and the strip looks like crap and the anesthesiologist is 30 minutes away if the doctor knows how to use forceps and thinks it’s the safest option I am glad it’s a choice. Of course, that wasn’t the point, the point is not to do forceps to avoid a c/s and that I agree with.
I don’t think anyone’s arguing for doing away with forceps altogether. The argument is against demonizing CS to the point where less safe alternatives are used instead.
I agree, it’s really clear that isn’t the intent. the conversation usually includes someone saying “I would never”.
I am so grateful to this woman for telling her story. I have listened in disbelief as some of my colleagues bemoan the decreased numbers of forceps deliveries in favor of c/s. I was born long after the hay days of instrumental deliveries but the descriptions of these deliveries are so vivid and the stats suck. The risk of serious trauma to the woman’s pelvic floor should not be ignored in the face of overall excellent outcomes from c/s. I’m thankful for technology that enables us to get a baby out vaginally and quickly when a life is at stake, but otherwise, let’s enjoy our easy access to the OR and competent surgeons, anesthesiologists, and support staff and spare women pelvic prolapse.
I do hope that VBAC will become more available for those women who feel they have to choose between instrumental deliveries and more than 2 or so kids.
I’m not an obstetrician so if I’m wrong please correct me, but I believe forceps take more skill to use than vacuum and in order to build and maintain that skill an obstetrician needs to do a certain number of forceps delivery in training and then on an ongoing basis. It’s a similar situation to how people bemoan the loss of vaginal breech delivery skills – it’s not ethical to use forceps instead of c section just so the doctor can have some practice.
I come from a country where in the (not so distant) past the drive to avoid c sections led to women suffering long term pain and disability from symphysiotomies. Vacuum and forceps certainly have their place, but promoting operative vaginal delivery for ideological reasons instead of safety reasons is not a good idea.
I specifically refused Ventouse (vacuum) delivery because I believe it is inhumane to the baby. A huge haematoma on my baby’s head is not acceptable to me.
You should have seen the giant bruise I was born with. It covered about half my face, and is captured in everything from flat photos to newborn keepsake lockets. From forceps.
My son was a ventouse delivery. Only a teeny hematoma.
In both cases, though, doctors were responding humanely to urgent needs. That isn’t always pretty.
Hematomas heal. Not everything does.
Forceps were responsible for Sylvester Stallone’s idiosyncratic speech (facial nerve damage) and Frank Sinatra’s scarred ear.
It isn’t as if it is impossible to cause injury to a baby with forceps.
I have to correct this. The most serious risk associated with vacuum deliveries is a subgaleal bleed. They are exceedingly rare but often lethal and almost exclusively associated with vacuums. It’s not the “chignon” or unique molding that the vacuum causes… and that’s not really a hematoma either, that’s just edema. (That’s nothing and taken care of with the evil hatting we do). It’s really common for nurses ( I am one and I have to admit this ) to call things that aren’t a cephalohematoma a hematoma. Those are collections of blood between the periosteum and skull and don’t cross suture lines. That is bleeding but limited usually because the membrane acts sort of like a pressure dressing. In a subgaleal bleed, which is the scary risk, there is nothing to slow the bleeding down in the scalp. But usually, as I said, its just caput molded into where the vacuum was and no big deal. But don’t mistake me for saying I am against all vacuums I am just frustrated by the perception that they don’t have risks too.
My child was delivered via ventouse. No visible bruise. She had a red mark that was gone in hours. She also didn’t die of hypoxia. I’ll take the red mark any day.
But that’s not the choice. The choice is forceps or Ventouse, and I specified that if it came down to it, I wanted forceps. I had already had two forceps deliveries so I was cool with them. As it turned out the baby didn’t need any assistance.
It is the choice sometimes. You love forceps, we get it. I am no obstetrician, and don’t have an informed opinion on forceps. But I suspect that tools have their places, and that assisted births might do better with forceps sometimes, ventouse other times, c-sections other times.
But my child was LGA and barely deliverable through my small pelvis. I’d been in labor for over 30 hours and on magnesium sulfate, and was the definition of “maternal exhaustion”. Think they should have shoved a piece of metal up in my limited pelvic space, too, when just delivering my large baby caused me to have permanent pelvic dysfunction? They didn’t ventouse her too hard, either. It was more of an assist than a yank
Good work side-stepping over the absolute fact that ventouse did not cause any visible bruising to my child, let alone a scary “unacceptable” bruise. It is not a given that the child will bruise.
Incidentally, a forceps delivery is partially why one of my friends became a homebirther. Her child has a rather large permanent scar on her face from the forceps. My friend also felt VERY traumatized by the forceps as a sexual assault survivor. She has sworn to never deliver in another hospital. That’s a very bad outcome – to decide to forevermore reject the safest place to deliver your children because you were subjected to a traumatizing forceps delivery that permanently scarred your child’s face.
Forceps are not always the right option for instrumental delivery, sorry. Congrats, they worked for you. Other people aren’t you. Become accustomed to the idea.
As for how my friend’s forceps delivery experience could have been improved: I have no clue. I wasn’t there, I have no idea if forceps were the right tool for her situation. I’m just the messenger.
Point of fact: Vacuum/ventouse assisted delivery is associated with a HIGHER risk of failure, HIGHER risk of shoulder dystocia, HIGHER risk of fetal trauma. Vacuum and forceps are NOT interchangeable. Forceps are better when you HAVE to get the baby out quickly, or if you’re concerned about a bigger baby. Vacuum is better if the mom is a motivated pusher, baby is in a favourable position, and head is very close to delivering. Both, wielded badly, can cause irreparable harm to babies, and neither should ever be performed lightly or carelessly. (I am particularly disheartened by the recent trend where clinicians use a vacuum indiscriminately because it’s the ONLY thing they know how to use.) (- I’m an OB with >10 years of 200+ deliveries/year.)
Yeah, I said I wasn’t an OB. You don’t have to be horrible to me about it. I’m pretty sure you weren’t the OB attending my birth, though, so I’ll defer to the people who were actually there.
(A small aside:
Lay MW’s, when you boast about your experience, please note that CanDoc manages over 200 deliveries per year. THAT is experience.)
Why the nasty reply to Fallow? As the patient, she didn’t have your level of knowledge or insight, and was not in the position to make the call. She could no more accurately assess her doctor’s level of skill with forceps or ventouse than she could compel him or her to use either one.
I don’t understand how CanDoc’s reply is “nasty.” Fallow admits ignorance (she is not an OB) and CanDoc replies with facts. I consider it very informative. What is the nasty part?
I’m sure it wasn’t intended to be unkind, and it’s not that offensive by internet commenting standards, but the tone seemed harsh and dismissive to me. Facts can be offered to inform, but they can also be presented in a way that is intended to contradict the statements of another. In this case, Fallow related stories that were relevant on a personal level. Why should she be lectured for being glad she had a ventouse and not forceps delivery, or for relating the emotionally charged story of a friend? I think if you read at the top of the comments, you’ll see that the comment was upsetting to Fallow.
Yeah, she took it personally. Despite the fact nothing in the comment refers to her. It is a Point of Fact: Followed by facts.
CanDoc said NOTHING about her personal stories, only about the overall situation.
And even if she did, and? If someone comes in and says, “I had a wonderful homebirth with a CPM,” would you complain if someone said: “Point of Fact: Homebirths with CPMs have 3 – 4 times higher risk of death to the baby” followed by a lot more stats comparing risks of homebirth to hospitals?
Not only would we not complain, we would explain nothing less. I don’t see the difference here.
That’s not really an equivalent example. Fallow didn’t say she had a wonderful ventouse delivery or try to imply that ventouse is a safe and ideal way to have a child. She related her own story, in which she had a ventouse delivery because her doctor thought it was indicated, and the story of a friend who’d had a bad experience with forceps. CanDoc’s response didn’t address any of what she’d said and appeared to be a sort of lecturing rebuke. It’s not the rudest thing ever, but I can understand feeling unjustly criticized, especially when you’ve related something personal and you get that sort of response from someone who is an authority.
But anyway, CanDoc very kindly replied that she hadn’t actually meant to respond to Fallow specifically and didn’t mean to offend her.
Having needed 2 forceps deliveries already, maybe it would have been kinder to your unborn child to schedule a c-section?
Improperly used forceps can cause pretty nasty injuries to babies. Which comes back to the learning curve required for forceps. A properly performed ventouse delivery or c section is likely to be superior to an improperly performed forceps delivery.
I always went to OBGYNs who were experts in obstetrics. The first one was a jerk as a human being, but she was still technically very good.
Good for you. It seems likely that forceps was the right choice for your particular situation. But if you refer back to my original comment you’ll see I’m talking generally rather than specifically about you. An obstetrician who is skilled with forceps may very well be a better option that a ventouse delivery. But being inexperienced with forceps has become more common in recent years. This does not mean that the OBGYNs in question are incompetent, but rather that they have not gotten the opportunity to perform many forceps deliveries while training. If a c section is a safer option than forceps, it is unethical to perform a forceps delivery just so the doctor can practice.
Im not saying forceps should never be used or that ventouse or c section should always be used. I just pointing out that the required operator skill is a major drawback of forceps.
How did you even know this? Really, I congratulate you on your level of knowledge and skill in choosing a provider. Personally, I had no knowledge of the skill levels of potential providers, no way to access this knowledge, and really not much information of the issues involved as a first time mother. I suspect most women are in this boat.
You know, when my second child went into severe distress while crowning, I knew that the vaccum was a distinct possibility if I couldn’t push him out in time. I was glad that I was able to deliver him without it, but yes, I would have done whatever was necessary to get him out safe and sound. My mind is a bit boggled that you were willing to argue about it in favor of forceps.
My best friend’s baby was delivered via ventouse, it saved her life with nary a mark on her sweet little head. I would much rather have this cheeky nearly 3 year old calling my phone at odd hours than potentially visiting a double cemetery plot.
But that’s not the choice. The choice is between Ventouse and forceps.
Ventouse, which delivered her baby safely and quickly when every second counts for a stressed baby, or forceps which would have been a poor choice with a large baby + small pelvis, probably causing more internal damage and making the situation even more traumatic. Just because you like forceps doesn’t make them a one-size-fits-all solution.
That was exactly my situation, for what it’s worth. LGA baby, small pelvis. She wasn’t quite too big for me to deliver, but she was cutting it close.
Oh Rosalind, you are too funny! You feel that it was wrong for Nurse Fischer to talk about the pelvic floor injury she sustained during a forceps birth because not all forceps births lead to pelvic floor injuries. But here you are calling vacuum births “inhuman” and implying that a hematoma is a typical outcome.
Here, I have a better solution: Let’s just tell the truth to women! Let’s not shame anyone into hiding the facts: Most forceps births don’t end in severe pelvic floor injuries, but the rate is increased. Most vacuum births don’t end in scalp hematoma, but the rate is increased. Most forceps births don’t end in skull fractures or facial hematomas, but the rate is increased. And give them the facts about the size of the increase, and what those injuries are really like for the personal involved. And then let women choose for themselves which risks are and are not acceptable to them personally!
Thanks. I didn’t know that my mother had harboured inhumane thoughts about me when she accepted the vacuum but it’s nice to be educated about this. And I normally buy 200 grams of other women’s hair to mask the fact that I have no hair on the place where the haematoma was.
Of course, on a serious note, I must say that I did have a haematoma. My head was a ghastly sight for a while, not only because of it. I am still alive, healthy, with all my brains intact and I am even bonded to the woman who chose this inhumane method of birth for me.
I am very baffled by your “inhumane” statement. In my book, inhumane would be to let the baby suffocate inside his or her mother. If forceps was so great in every situation, vacuum would not have been invented, IMO.
Good for you, I guess. You decided which risks were acceptable to you, sought out a provider who would honor your preferences, and were happy with the outcome. Great. But what does it have to do with anyone else’s experience? Your fab forceps deliveries don’t negate another woman’s incontinence or someone’s forceps-related birth injury or someone else’s positive vacuum extraction.
The fact that you had an uneventful experience doesn’t mean that other women shouldn’t be told about the risks (not certainties) of one mode of birth versus another, or that those risks shouldn’t be considered when people are contemplating sweeping policy changes favoring one mode over another.
“I do hope that VBAC will become more available for those women who feel they have to choose between instrumental deliveries and more than 2 or so kids.”
I agree. Although there are always the cases of women who want large familes but who wouldn’t be good VBAC candidates. I am thinking of a woman in our system who comes from a culture that has traditionally prized very large families. Her pelvis is shaped such that her babies have all gotten “stuck” at the same point because of the same malposition issue. Each time a mid forceps in skilled hands has resolved the issue. They always call in one of “The Old Guys” if one is not in house already. She’s on baby #8 now IIRC.
My cousin is in her mid to late 40s and is a forceps baby. She suffered severe damage. She drives, graduated from school, and currently lives alone. You can have a conversation with her and she’ll discuss books and movies absolutely normally. In fact, they figure she’d have had a genius iq if not for what happened. Thank god for that, because she is borderline now. It’s hard to explain. You’d know something was wrong but not what if that makes any sense. Because she can discuss everyday things but then she’ll do things like leave her purse in the car with the window down.
I guess it’s kind of like dementia actually. She lived with my aunt always until my aunt died suddenly. Her sisters won’t take her in because they’ve got their own families and a little brother who had just graduated high school (they are spread out a lot in age). She had a job at a hospital cafeteria for 19 years and they piled too many things into her…she couldn’t remember the new duties and they fired her (she’s pursuing it as she IS disabled). This all happened four years ago. She still can’t find a job. She lives alone now but her sister pretty much has to pay her bills for her because she’d spend it all without thinking.
She says she can work so the SSDI people keep turning her down but her hands tremble with nerve damage, she’s blind in one eye, she has water on the brain and an MRI report said the brain of a 70 year old. So no one will hire her but SSDI just keeps ignoring those reports because SHE says she can work. The reality of it is that she cannot.
THAT is a forceps baby. I could’ve been one, too. Apparently the doctor put her HANDS in my mom and pulled me out that way. I guess I was turned in some way so the OB turned me. But she could’ve ended up using forceps. I am totally against them after knowing my cousin. C-sections ALL THE WAY. I guarantee my aunt would have preferred that, even though she loved my cousin desperately. But it was so senseless.
I’m not trying to downplay your cousin’s story, but I’m a forceps baby too with none of those issues. I would not choose to deliver by forceps over a c-section now, but I’m not sure that my mother made a terrible choice 40 years ago, especially as I was the first and she was planning at least a few more kids.
My thought too, that it could be the reason they did the forceps rather than the forceps themselves. But of course we weren’t there.
In this case, I know for a fact that it was the forceps themselves. They essentially smashed in one side of her face. By all rights, she should have died from her injuries. The damage was on one side of her head only from what I understand.
That’s awful. I have heard of such things, never seen it and hope I never do. Years ago things like high forceps and forceps rotations were done. My point was that brain injury happens from oxygen deprivation too. And sometimes it’s also true that forceps are be used to hasten a delivery where the baby is showing signs of distress. On the other hand, while by 40 years ago this was not as true, in the 1950s and 1960s forceps were almost routine as I understand it. I was a forceps delivery, it sounds like my sister was a forceps rotation, she’s brilliant and perfect…me, must be the forceps. But seriously I believe you and that must be so painful for your family.
I hear you. And I don’t mean to make it sound as though forceps always or even commonly cause problems.
But in this case we know for a fact it was the forceps. The damage was clear when she was born. Her eye was the direct result of the damage.
Your cousin sounds a lot like my brother-in-law. He suffered some sort of brain injury during delivery (probably through oxygen deprivation) and is now in his 40s with a moderate intellectual disability. Luckily for him and his family, he lives in Germany, which has a better system set up to assist disabled people than the US does. My brother-in-law has his own apartment, and a job in a sheltered workshop making calendars and bed frames.
I wonder if the city or town where your cousin lives has a Disabilities Services Office. This may be a good place for your family to turn for help. Of course you can’t force your cousin to accept any help or services (presuming she doesn’t have a legal guardian), but they might be able to give some advice to her siblings or other relatives. Just a thought, 🙂
Also, your birth sounds a lot like mine, too! The story I heard is that my mother had been pushing all afternoon when a nurse walked by and exclaimed “Why is this woman still here?!” Then she pulled me out, without forceps.
I have repeatedly said that she needs to be placed under a conservatorship but my family doesn’t listen. I’m an attorney and while I don’t do work like this, I know enough to give decent advice and they just don’t listen. It’s really frustrating. It’s also frustrating because her sisters won’t take her in even though otherwise they are a very close family. I mean, I do understand why they won’t… but they could if they had to. And what’s worse is her dad won’t take her in either. He sends her like $1000 every month and I think that’s what she lives on along with whatever the portion of her mom’s insurance money is, if there’s any left (her sister DID hold onto that and I think doles it out).
She has an attorney and has been through several appeals with SSDI. She needs to stop saying she wants to and can work, because the reality of it is that she can’t. The reason she got fired was because the cafeteria told everyone to carry thermometers around with them and check food temps (they’d been dinged on that by the state) and then record them like every hour and she couldn’t get that done in addition to cleaning and checking people out. 1) she is just slower than others because of her tremors and 2) she would just forget. And they knew about her limitations. They didn’t accommodate her… they just fired her. So she’s got a complaint with some state program that handles these types of things… some kind of administrative thing that can slap the wrist of the employer instead of a lawsuit.
My mom would have let her live with my parents but my daughter and I stay with them most of the time right now and there’s just not enough room for her as well.
Losing her job, which she had for almost 20 years (there goes the full retirement), was a blow. When my aunt died, it was horrible. She was the first person everyone thought of. She’d never lived alone up until that point. The fact that she does now is great.
I had two forceps babies who are both extremely intelligent and completely neurologically normal. To suggest that all forceps babies are in some way impaired, as you do, is dishonest and mischievous.
Was she really suggesting that? I just read it as an example of what can happen as a result of a forceps delivery. Can happen, not will happen.
Look at what she wrote. ‘THAT is a forceps baby.’ She’s implying that all forceps babies are like that. Totally untrue.
Well, that IS a forceps baby. As are your babies. As is my nephew. Your good results don’t negate someone else’s bad ones. The truth is that most forceps babies do very well indeed, but some do catastrophically poorly. Women should know that the risk of neurologic damage to babies is higher with a forceps birth.
NO, it isn’t. Risk of neurological injury is HIGHER with both vacuum/ventouse delivery or cesarean section that forceps delivery. ( http://www.reuters.com/article/2011/11/30/us-forceps-delivery-tied-lower-brain-inj-idUSTRE7AT2JG20111130 )
– CanDoc, Professor of Obstetrics and Gynecology who believes that women need to know that evidence to make informed choices, not the scare tactics provided by anecdata
Whoa. You really need to clarify that statement as it sounds as though you are claiming that CS cause neurological injury. Sure, you will see higher rates of injury after delayed CS or CS performed for distress or complications, but it was not the CS itself that caused the injury. A pre-labor CS is very unlikely to cause injury to a baby. Women should know this as well.
Are no. Pretty sure she’s implying that if a baby is like THAT, then it is likely due to forceps. Not that if a baby is delivered by forceps, it will by like THAT. i.e. she’s saying that if A then B, which is NOT the same thing as saying all B’s are A’s.
I don’t get you, Rosalind. Look, it’s fantastic that your forceps deliveries didn’t leave you or your children with lasting damage, but we know that at a population level, forceps is the worst method of birth in regards to pelvic floor damage. I don’t have any desire to see a routine return to mid to high forceps deliveries except in emergencies.
The reductionist thinking that forceps “caused” a problem is both mechanically and scientifically unsound – forceps provide at the level of the jaw to deliver the baby, and have a much LOWER association with brain damage (bleeding in the brain) than vacuum/ventouse deliveries. ( Eg, http://www.reuters.com/article/2011/11/30/us-forceps-delivery-tied-lower-brain-inj-idUSTRE7AT2JG20111130 )
The more likely event, especially 40+ years ago, is that an event during labour, such as asphyxia, lead to brain damage – not the forceps themselves.
“The reductionist thinking that forceps “caused” a problem is both mechanically and scientifically unsound ”
Mythsayer’s cousin was born with one half of her face smashed in. It’s not reductionist to say that the forceps caused that in this case. Forceps in skilled hands are an amazing thing. And statistically the vast majority do well. That doesn’t mean we have to gaslight people or their families who were clearly injured.
Not gas lighting at all: I don’t see any comment that her eye/face was “smashed in”, but instead that she is blind in one eye, has significant cognitive irregularities and delays, and apparently hydrocephalus (water on the brain). All of these can be associated with asphyxia or pre-natal events. I’m not saying that this woman doesn’t have delays or challenges, just that it’s possible (dare I suggest probable, given the constellation of abnormalities) that forceps weren’t the cause.
Read down on her comments further. She specifically says that one side of the baby’s face, including the eye area, was smashed in, and that the baby barely survived the injury.
It’s awful. It is heartbreaking to think what your cousin might have been and will never be. I think every human being deserves a safe entrance into this world and becoming what they were meant to become genetically. I used to live next door to people whose only son was severely handicapped due to forceps delivery because c-sections weren’t so common in those days. When you actually SEE such outcomes you clearly understand that numbers are just numbers and making them more beautiful i. e. the dreaded 33% into the desired 15% is nothing compared to a lifetime of misery to two people at least (mother and baby) not to mention of the rest of the family.
What is the definition of “operative vaginal delivery”? Examples?
Vacuum or forceps
My Baby A was delivered by vacuum, after he started having late decels. Aside from some odd moulding (which resolved in a day or so), he suffered no ill effects. It only took one pull (with me pushing) to get him out. I think it was probably faster to try that, vs. a Csection, especially since he was just starting to show signs of distress. I got a tear from it, but it was a minor tear.
I have a friend though, whose baby was stuck, and they tried the vacuum. They pulled a few times, and he didn’t budge, so she ended up with a Csection. Her baby was fine, not sure if she suffered any pelvic floor damage.
My vacuum delivery was similar, although with two pulls rather than one. But I believe vacuum deliveries, particularly relatively non-drastic ones like ours, are a different beast altogether to forceps.
The data is very clear that forceps increase the morbidity to the mom. And while I want to be clear I am not saying that vacuums are better/worse the data I read, and experience, is the counterintuitive result that actually there is more serious neonatal injury statistically from vacuum delivery. I just googled vacuum vs forceps and there are good articles on it. The thing is that serious injury to the baby with either isn’t that common, while injury to mom with forceps isn’t all that rare. It’s one of those rare logical things that it’s just obvious forceps are harder on mom’s tissues when you see what happens. But what’s not as obvious is that the big metal spoons seem to be less associated with really serious injury than the soft plastic cup. There are anatomical things about the fetal scalp that give vacuums unique and not unheard of serious risks of their own. Both have serious risks and really, the main point of the article is good, that a c/s is usually a better choice.
I don’t know that a section would be the better choice in the circumstances mine and Amy’s vacuum deliveries were performed in, though. No expert here, but I believe a vacuum delivery with just one or two pulls and minimal tearing would usually happen when the baby is pretty low already? Sections in those circumstances are not ideal (I’m not section demonising here btw, I’ve had one).
Where there perhaps is an argument is for situations that are more likely to lead to instrumental delivery, such as PROM or back to back (or both as with my first!) to be offered a section before things get to the ventouse stage. That is, before an instrumental delivery becomes the safer option.
I think it’s a hard thing to discuss because it’s so nuanced. It’s also, in real life, pretty intense situations. I would definitely support either choice, having the c/s or doing the easy vacuum delivery. Both have risks. This is the stuff that makes OBs say things like what was wrong with ophthalmology or labor nurses think of opening a sock boutique.
I specifically told my OBGYN he could do anything but a Ventouse delivery precisely because I think it is inhumane to the baby. It may do no lasting damage but no baby of mine was going to be born with a haematoma on his/her head.
We always had a “three pop offs and your out” policy for the vacuum. I wonder if that’s the case everywhere.
Vacuum (ventouse) or forceps delivery.
There are a variety of vacuum devices, from the classic hoover-like giant ventouse machine to small handheld vacuum devices like the Kiwi.
…am even more grateful for my C-sections now.