In our obsession with lowering C-section rates, there has been much handwringing over the lost art of forceps deliveries. The dramatic rise in C-section rates has been caused in part by the fact that many deliveries that would have been accomplished by forceps have become C-sections because of our reluctance to use forceps. But there’s a good reason why forceps have gone out of fashion: they are much more likely to harm a baby than C-sections.
This hideous case is just one example: Mom blames newborns’ death on doctor’s use of forceps.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We shouldn’t lament the passage of forceps into history [/pullquote]
A Long Island obstetrician allegedly used forceps so aggressively during a delivery that he severed the infant’s head internally from his spine, according to court papers.
A devastated Megan Stirnweiss, 23, says her nightmare began when she went to Southampton Hospital in labor Dec. 30, in a last-minute decision after her home delivery became too painful.
What happened?
The doctor put forceps around the baby’s head and yanked, dragging Stirnweiss — who was holding onto the bars of her hospital bed — all the way down to the edge, court papers say.
Then “he pulled the forceps that he had around the fetus’s head, lifting [Stirnweiss] off the bed by the forceps around the fetus’s head, and shook her vigorously until the baby was delivered at 2:56 a.m.,’’ according to the lawsuit…
The baby — who “was internally decapitated” — was whisked away, the papers state.
As for Stirnweiss, she “suffered disruption, dislocation, tearing and lacerations of her internal organs and structures,’’ her suit says. She now “is in constant pain’’ and will “require reconstructive surgery,’’ the papers state.
The accompanying picture of the baby adds more detail for those who know where to look. While the doctor may or may not have used excessive traction, one thing appears indisputable; the doctor did not put the forceps on properly. Forceps are designed to rest over the baby’s cheeks. This baby has an obvious imprint of a forceps blade over his forehead, extending to his eye. The forceps application wasn’t even close.
This highlights a fundamental difference between forceps and C-sections. Forceps use requires far more skill than performing surgery.
As Atul Gawande wrote in a fabulous piece entitle The Score:
“Forceps deliveries are very difficult to teach—much more difficult than a C-section,” Bowes said. “With a C-section, you stand across from the learner. You can see exactly what the person is doing. You can say, ‘Not there. There.’ With the forceps, though, there is a feel that is very hard to teach.” Just putting the forceps on a baby’s head is tricky. You have to choose the right one for the shape of the mother’s pelvis and the size of the child’s head—and there are at least half a dozen types of forceps. You have to slide the blades symmetrically along the sides, travelling exactly in the space between the ears and the eyes and over the cheekbones. “For most residents, it took two or three years of training to get this consistently right,” he said. Then a doctor must apply forces of both traction and compression—pulling, his chapter explained, with an average of forty to seventy pounds of axial force and five pounds of fetal skull compression. “When you put tension on the forceps, you should have some sense that there is movement.” Too much force, and skin can tear, the skull can fracture, a fatal brain hemorrhage may result. “Some residents had a real feel for it,” Bowes said. “Others didn’t.”
Back when C-sections were considerably more dangerous than they are today, fetal injuries caused by forceps seemed like a reasonable trade-off for avoiding a procedure that might kill the mother. Once the C-section became as safe as it is today, harming a baby’s health and neurological function no longer seems like a reasonable risk.
It is important to note that there are different types of forceps deliveries. Outlet forceps, as the name implies, are used only when the head is extremely close to delivery. These forceps shorten the time to a birth that was going to happen anyway. They are often used to shorten labor when fetal distress is diagnosed and they rarely cause injuries.
Mid-forceps, in contrast, are used to deliver a baby that is stuck despite what appears to be a large enough maternal pelvis. They involve far more skill, far more traction, and far higher risk of injury. The most dangerous mid-forceps procedures are mid-forceps rotations. These are used to turn a baby in the unfavorable occiput posterior (OP or “sunny side up”) to the more favorable occiput anterior position and then traction is applied to deliver the baby. Not surprisingly, these procedures require the most skill of all and pose the most danger to both baby and mother.
The potential danger to the baby is obvious: fractured skull, neurological injury, and internal decapition (fracturing the top of the spine). The potential danger to mothers is also significant: far higher rates of anal sphincter injuries and subsequent problems with continence and sexual function.
Mid-forceps, and in particular mid-forceps rotations, are used to deliver babies that probably will not come out or will not come out alive if nature is left to take its course. If the baby cannot be delivered, the mother will die, too. So allowing a woman to push more than 3 or 4 hours in this situation won’t result in a vaginal delivery. The only choice is between forceps and Cesarean.
Most mothers and many obstetricians think it’s no choice at all. A C-section, which involves slightly more risk for the mother and virtually no risk to the baby, makes more sense than forceps, which involves very significant risks to the baby and risks to the pelvic floor of the mother.
Had this doctor opted for a C-section instead of forceps, both the baby and mother probably would have done fine.
Instead:
Stirnweiss, a cook for the US Coast Guard, said she and her husband kept their baby alive on machines for seven days so that his organs could be donated. A baby from Toronto, Canada, received Matthew’s lungs.
“He gave the ultimate gift of life,” she told The Post of her son.
Is this an indictment of all forceps?
Dr. Steven Goldstein, a professor of obstetrics and gynecology at NYU Langone Medical Center who is not involved in the suit, told The Post, “This is a terrible case.
“This is very sad, but this is not necessarily indicative of the way that forceps can and should be used,’’ he said. “Some forceps are still very safe.”
That’s true. Outlet forceps are very safe because the baby would have eventually come out vaginally in any case. But mid-forceps, the forceps procedures that have been replaced by C-sections, have major risks to both babies and mothers. No one should lament their passing into history or the higher C-sections rates that result.
Would it have been different if she’d gone to the hospital for the birth instead of trying the other cult-like thing–a home birth?
And who, these days, remembers the unlamented ‘high forceps’ – defined as applying forceps to the unengaged head? Absolutely no end of mischief could ensue, given you could apply the forceps and pinch the cord, never mind there was no indication that you were pulling as hard as you could on an impossible CPD. That was already considered a bad idea in the 1970’s when I trained. The ventouse hadn’t yet come back into fashion and was laughed at, and most forceps deliveries then were outlet forceps for a mother exhausted by the second stage. I liked those little Wrigley forceps. Good for the aftercoming head of a breech too, as in those days a breech wasn’t an automatic section. Not keen on Kielland’s though, and honestly, no one who hasn’t used them a lot ought to ever lay a hand on them.
When I began my career in 1967, mid-forceps deliveries had already been declared obsolete and C/S was the preferred method. Even the Scanzoni Maneuver for persistent occpito-posterior was being done less and less.
Wow. I was a forceps birth in 1974. All I know is that my mother was put under GA, and later the doctor said it should have been a c-section. Other than a bruised cheek and a broken coccyx, we were fine though.
As with breech births, doctors used to get vastly more experience with “operative obstetrics” before the “epidural era” began, allowing safer C/Ss. Being unskilled is always dangerous, and nowadays, in our part of the world at least, a C/S is much safer than other methods.
No argument from me – I just didn’t realize forceps were already on the way out when they were used on me.
I’ve got you beat- I was a mid-forceps birth in 1994! I was born in a tiny regional hospital that was not equipped for emergency C-section (only one operating suite, etc). Births judged high-risk were referred to the university hospital and hour and a half away. I was not high risk, so my mom labored at the smaller hospital. Despite the low-risk designation, I got stuck and went into distress. The operating suite was in use, so the only options were forceps or life flight to the larger hospital. The life flight would have taken at least half an hour to get me to an OR. My mom opted for forceps. Luckily, I wasn’t injured and my mom said she didn’t notice any pelvic floor issues she wasn’t already dealing with from my sister’s birth two years before. Still, it’s very uncomfortable to think that I could have been this baby.
I saw Romanian doctors in Israel in the 80s do exquisite mid-forceps deliveries. They were really artists, and when I asked why, I was told that C/Ss were almost completely impossible to obtain under the Caucescu regime, and unless delivered by mid forceps, the mother would die, so they got lots of experience.
Outlet forceps, when the head is crowning but pushing just can’t get it that last tiny bit, often because the perineum isn’t flexible enough, are still fairly common. MID forceps, which essentially drag the baby by the head through the pelvis, are obsolete.
I never wanted to read the words ‘decapitated baby’ ever again. It’s utterly sickening. Those poor families.
Horrific. No words.
From a family member whom shared the article;
To all of my Facebook friends and family:
This year the unthinkable has happened to my family, specifically my sister and her husband. We appreciate if you share this story, so this will never happen to another family.
On December 30, 2017 my sister’s water broke at 5:15 AM, after hours of not dilating past 6cm she arrived at Southampton Hospital at 4:15 PM. My nephew and Godson, Matthew Jacob (Matty J) was born the following day at 2:56 AM. Due to the wrongful use of forceps (internal decapitation) along with the negligence to give zero sonogram and a cesarean, Matty J is no longer with us, but gave the ultimate gift of life by a double lung transplant to a 4-month-old baby boy in Toronto, Canada.
This hospital and these doctors are in our County, and their patients are our friends and neighbors.
Any and all prayers and thoughts are needed and appreciated for my strong sister, serving Active Duty Military on Long Island in the US Coast Guard.
Any questions or inquiries please contact Christine at The Law Office of Robert F. Danzi (516) 288-4226
This is just awful. That poor family.
Guys, does anyone know why one would opt for a ventouse vaccum vs foreceps? I know squat about the pros/cons relative to each other. (FTR, I myself was a ventouse baby. Thank you, ventouse!”
I had one, the issue of forceps wasn’t really raised but as I understand it ventouse is considered preferable when the baby is really far down, as mine was. Literally only needed two pulls, head kept poking through then going back up. The risk of damage to the mother is lower with ventouse. NHS says severe tear is twice as likely in forceps as ventouse.
https://www.nhs.uk/conditions/pregnancy-and-baby/ventouse-forceps-delivery/
Anecdotally I think they use ventouse when baby is further down, even when compared to only low forceps deliveries. Obviously high ventouse wouldn’t be possible, whereas high forceps isn’t advisable nowadays but is a thing.
Provider preference. You dont want me attempting a forcep delivery, but I do a nice vacuum if needed & with consent.
My husband did plenty of assisted calf deliveries on the farm – and he would have gone bonkers if anyone recommended a mid-forceps delivery of a human baby when a CS was available. (He’d be OK with a careful outlet delivery; it saved both his older brother and him.)
In cows, we apply traction on the calf’s limbs and once in a while apply gentle traction using a hand or a noose to move a calf’s head into the right position. A dam is huge compared to a human and a stuck calf is usually over 100 pounds; neither is nearly as fragile as a newborn human or a woman’s reproductive parts.
Even with those caveats, an poorly trained person can maim or kill a calf pretty easily using ropes or chains. Applying too much force can kill the dam from a broken pelvis, nerve damage preventing her from standing, shock or bleeding which is why calf-jack deliveries were only done by highly trained operators.
Operational vaginal deliveries are no joke – and I don’t think the mid and high ones have any place in developed nations with access to safe caesareans.
Sure, I could probably make my family’s winter coats, but the store bought ones are both easier and more effective at keeping them warm while allowing free movement, so why should I bother?
And a poorly made winter coat won’t damage or kill anyone.
could, depending on the viciousness of your winter.
Educated guess: it stated she was planning a home birth. Most OBs would not do this type of forcep delivery, but I’m guessing there was refusal of section.
Again, very incomplete info, but it is probable, at least in my experience with homebirthers who end up in the hospital.
A tragedy all around.
From family member, “my sister gave consent for cesarean upon arrival at the hospital, is indeed a case of negligence to perform cesarean among other things”
I too would like more information about her pre-natal care, who was with her when her water broke & she was in labor, etc.—particularly the statement “among other things”. She wouldn’t have “given consent upon arrival at the hospital”—consent for surgery is done prior to surgery being performed, not as a general paperwork type of thing. The doctor would have told her that he recommended a c-section & she would have to sign a specific consent form, as well as have a pre-operative anesthesia consult to decide if she would have a spinal or epidural anesthesia for the birth. I have a feeling there’s more to this story than what’s being said. It is a tragic outcome, no doubt, but there’s more to this story. I would like to know exactly why she went to the hospital, how she got there, who her GYN is/was, who did her prenatal care, when her last sonogram was before she went into labor & if there was a midwife that was with her at home for the planned home birth.
Its none of our business but you may be right.
What a sad case. At the Birth Trauma Association, we hear a lot of terrible stories about forceps births (in fairness, we hear stories about traumatic caesarean births too). It is worrying. If a woman isn’t planning a large family, then it seems the balance of risks arguably tips in favour of caesarean rather than forceps. In Australia, Peter Dietz, an obstetrician who repairs childbirth injuries, has argued that as a result of the drive to reduce caesarean births, he’s seen a rise in forceps injuries.
I’ve been reading Maggie O’Farrell’s book I am, I am, I am, about her 17 brushes with death. One of them is her account of an emergency caesarean, which is partly based on an earlier article she wrote for the Guardian in 2004. It’s worth reading this because it says so much about the way the medical establishment treats pregnant women. https://www.theguardian.com/society/2004/may/21/health.medicineandhealth
Great article. Her doctor sounded horrendous, though.
Yes. Unbelievable, really.
My last forceps related death (at autopsy) was about 10 years ago. I’ve had 3 over the course of 25 years but none for years now. It could be that obstetricians are more proficient, but I think it’s probably because section is more often the first choice and mid-forceps aren’t as commonly used. My first case was occipital osteodiastasis, when innapropriate placement pushes the squamous part of the occipital bone inwards to tear the venous sinuses and then cerebellar tissue embolises. We found cerebellar tissue in the baby’s blood vessels in the lungs. It’s something I never want to see again.
Only understood about half of that, but that half, holy f***
Basically, the skull bones separate, the sharp edge of the skull plate at the back of your head gets pushed in towards the meninges and underlying brain. It’s not uniformly lethal, but it can cause subdural haemorrhage and disruption of the cerebellum, or worse. If it’s pushed in far enough, the big draining venous channels around that area can get lacerated by the bone edges and the fragmenting cerebellar tissue can get sucked into them. Circulation takes it to the heart, and then it ends up in the lungs and elsewhere. In the non lethal cases, the skull bones separate but there isn’t as much trauma to actual brain, so there’s a spectrum really. To be fair, it doesn’t just happen with misapplied forceps, it can be caused by a difficult breech birth.
Bits of brain in veins?
Absolutely horrifying!
I’d never seen it before-we have training covering birth related trauma but that was predominantly subgaleal haemorrhage, subdural haemorrhage, bit about internal decapitation, skull fractures etc, and this had only ever been mentioned in passing. I was a fairly newly appointed consultant at the time (that’s the equivalent of USA board certified attending docs), so I called in a bit of help-the professor that I’d done some of my training under and a neuropathologist . It’s the sort of case you need to get absolutely right for everyone’s sake-parents most of all, but also the clinicians so that we can work out exactly what went wrong, thankfully (maybe that’s the wrong word under the circumstances) my prof had dealt with a case like it years ago. It was very odd seeing perfect little strips of internal granular cell layer complete with purkinje cells from the cerebellum wedged in pulmonary vessels.
You can be thankful that you knew someone with the right expertise to answer what had happened for the sake of the family (and the clinical team).
“Some forceps are very safe”? Seriously, that is the argument in support?
Comparing forceps to drunk driving is not a good analogy. Some forceps (outlet) really are low risk and are lifesaving (baby needs out NOW, not in the 20 minutes it would take to do a CS, and not with the risks of pushing the baby back up from so low.) Even mid forceps have their place for women who want a huge family. Drunk driving never saves lives, the best you can hope for is that nobody is killed. In contrast, forceps have an important (albeit now rare) place in medicine.
I can imagine situations where it could
But it’s not about drunk driving, it’s about the dumbass argument that this situation is “not indicative of the way that forceps can and should be used.”
If you don’t like the drunk driving substitution, put in a gun. The defense is worthy of the NRA.
“It’s about the dumbass argument that this situation is “not indicative of the way that forceps can and should be used.”
I disagree. I think it’s a reasonable argument in this case, because these forceps were used incompetently, likely to the level of malpractice. Imagine a situation where a doc commits malpractice killing a woman during CS by slicing into her bladder and not noticing. Anti-CS activists would try to use this example to demonize CS. But you could defend CS by saying “this is not indicative of the way CS can and should be done. CS is still very safe” Or imagine a baby that dies when its parents feed it formula made with dirty stream water while on a camping trip. Lactivists would try to demonize formula. One might defend it saying “This is not indicative of the way formula can and should be used. Formula is still very safe.”
You’ve changed his argument.
“Formula overall is very safe” is NOT the same as “SOME uses of formula is very safe.”
He never argues that forceps are safe overall. He is arguing that sometimes the use of forceps is safe. His defense is like saying “Some spins on the roulette wheel are very lucrative.”
No. He basically says “this is not when and how forceps should be used”.
Which is completely correct. As several posters with a medical background have explained, there are situations in which forceps are appropriate and a safe option: Namely when the baby is almost out, and just needs to go a bit quicker.
And there is a way of using them safely in that situation: By applying just the right amount of hold and pull, instead of yanking at the baby’s head.
It’s a false comparison. In developed nations, there’s seldom reason to use mid-forceps. Those cases can and should be Cesearians. But outlet forceps are still very necessary. You can’t perform a c section on a baby who’s already in the birth canal. In order to go c section in such a case, you’d have to push baby back up into the uterus, which is in itself a risky procedure, and delays removing a baby exhibiting severe fetal distress. At that point, outlet forceps *are* the correct answer.
Drunk driving doesn’t have that kind of distinction. If you are intoxicated, and you operate a vehicle, you’re wrong. Period.
Well if it is Period,then that ends the discussion. Or not.
As I told 50501, I can imagine situations where drunk driving is the best option.
But then again, that’s all a strawman. It’s not about forceps or drunk driving. It’s the logic behind the apologetic. It fails.
I was a forceps baby. But in the 70’s. In the UK. My mother tells me that most of her friends at the time had forceps deliveries. When I delivered my huge baby, I asked my OB about forceps. He was super old school (now probably 70y) and was totally comfortable with the technique. But said that he hardly ever taught resident because a section was so much safer. It is truly a dying art. But for good reason, given the safety of a section. I think I’ve only ever seen forceps used a handful of times out of the hundreds and hundreds of deliveries I’ve seen. I hope we never return to a time when forceps are safer than a section.
I’ve heard the UK has a higher forceps rate than most other high income countries.
That’s true. The UK still uses forceps more frequently than they are used in the US because they want to reduce the C-section rate, regardless of safety concerns. C-sections are more expensive and the NHS is a public health system so official NHS guidelines specifically encourage ‘trial of forceps’ prior to any C-section (as long as it is medically safe to do so) and they also encourage home births in order to reduce costs.
I’m surprised to read that this story happened in the US, actually, because doctors here rarely use mid-forceps anymore due to the risk of malpractice suits. There have been a number of high profile malpractice suits even in the UK relating to the use of forceps and resulting death or injury of mothers and babies.
Of course, it’s a false economy on the part of the NHS because if you take into account litigation as the result of failed forceps births, and the costs of treating a woman’s poor mental health as the result of a traumatic forceps delivery, it’s at least arguable that a forceps birth works out more expensive.
This is going to sound callous, but in the NHS, a dead baby costs the hospital/NHS far, far less than a brain damaged one.
Whatever else it might or might not sound, it’s also true.
Agreed, and it’s my understanding that this is why our litigation bill is so astronomical here in the UK. It’s tragic that it has come to this, but I think this is the only way the NHS will clean up its act on this issue.
Does anyone happen to know how much we are using ‘mid’ forceps here in the UK? Anecdotally I don’t think they are that rare – I’ve even seen them on ‘one born every minute’, in a scenario that certainly didn’t seem like a huge emergency or a one-off.
Are rates of forceps (and the types being used) actually monitored anywhere, or is the entire system so cock-a-hoop about caesarean reduction that nobody’s bothered to keep track of them?
Rates of forceps yes. NHS have stats on this. I don’t think they differentiate between type though. I agree there’s a world of difference between low and mid. That’s not to say that some low forceps cases might’ve been better as an earlier section, but it’s possible for the baby to be far down enough that instrumental is safer than section. Less easy to see how mid forceps would be, notwithstanding some women would particularly want to deliver vaginally if eg they plan lots more children.
About 12% of births in England are either by forceps or Ventouse – I believe it’s roughly half and half. In 2000 forceps births reached an all time low of 3%, but they have doubled since then. Latest stats here: https://files.digital.nhs.uk/pdf/l/1/hosp-epis-stat-mat-repo-2016-17.pdf)
Sections aren’t even more expensive according to NICE, but yes, I suspect the desire to keep rates low is relevant.