No-one wants to have an instrumental delivery, and no doctor really wants to perform them! When you are pregnant, practicing hypnobirthing and having a positive mindset as you approach labour and birth, a potentially complicated delivery may be the furthest thing from your mind.
However, I strongly believe that knowledge is power, and being prepared for all outcomes can be the best way to have an empowered birth, whatever happens in the end!
As a result, I think it is brilliant when women are familiar with instrumental deliveries, including ventouse and forceps, before labour begins. In fact, it is a really important part of the antenatal classes I teach. However, you may also hear horror stories from friends and families who have instrumental births which may affect your on view on this.
As an obstetrician it is extremely difficult when patients decline forceps, especially at the critical moment. So, before deciding if you wish to refuse them, it’s important to know a few key facts:
1. Why are they used?
Forceps are used to assist the delivery of your baby’s head in a situation when the head is very low in the birth canal and either;
💥baby is in distress or
💥baby is not delivering with pushing alone.
Applying forceps is never a first choice, but sometimes it’s necessary to give a bit of help to bring the baby’s head lower whilst the mother pushes at the same time.
2. What are the benefits?
- Having forceps helps to deliver your baby quickly, reducing any time they may be deprived of oxygen if there are signs of distress on your baby’s heart trace.
- Successful forceps means you may avoid a C section, so reducing the risks of complications that a major operation involves
- Without a C section, you will recover quicker from birth.
- Vaginal delivery (even if assisted with an instrument) means you are likely to achieve an easy vaginal delivery in your next pregnancy.
3. What are the risks?
Forceps delivery does increase your risk of third and fourth degree tears (which involve the anal sphincter) by up to 7%.
💥This risk can be reduced by performing episiotomy at the same time as well as the doctor or midwife supporting the perineum at the time of delivery. Perineal massage can also reduce this risk!
4. What are the alternatives?
If you decline forceps when your baby is that low (ie you are fully dilated and the head is close to crowning) but your baby urgently needs to be delivered, the only option would be an emergency c section.
This can be risky to both mum and baby, and doesn’t necessarily change your likelihood of having incontinence or prolapse in the future, because pregnancy in itself can give you this risk.
The main reasons it is risky is because:
- At fully dilated, the baby’s head is likely to be very low in the pelvis meaning that to deliver the baby via the abdomen, the head would need to be brought back through the vagina and dilated cervix.
- The risks to the mother include:
- Risks of lacerations/ tears in the vagina and cervix whilst delivering the head
- Increased risk of post-partum haemorrhage
- Higher risks of damage to bladder/ bowels during the C section due to close proximity when the cervix is fully dilated
- It also increases the risks of preterm delivery in future pregnancies
- Risks to the baby include:
- Risks of trauma such as scalp and facial bruising, or more rarely more significant injuries such as heavier bleeding or damage to the clavicle
- Increased risk of admission to special care after birth
In emergency situtions where there is little alternative, eg when instrumental delivery was attempted but didnt work, these risks are acceptable when balanced against the risks of other options.
However it is important to be aware that C section isnt always a straight forward option.
5. I still don’t want forceps – what now?
If you feel strongly you don’t want forceps, I recommend discussing that with the team BEFORE labour. They can explain all the risks and benefits of being open to a forcep birth. The best opportunity is during antenatal appointments, and if you are seeing only midwives then they may wish to refer you for further discussion with a doctor before your preferences are noted on your medical notes.
If you still refuse, then you understand and acknowledge that if forceps are not an option, you have a higher likelihood of ending up with a C section if there are any issues. This will be added to your notes, but you should be prepared to discuss it again once labour begins, as it is likely you will see a different team of doctors and they may wish to explain everything afresh.
However, ultimately it is your body, and you do have the right to refuse any procedure at any time! Ask as many questions as you need to feel comfortable, and you can also change your mind as the situation progresses.
How did you feel after your forceps birth? Do you feel strongly about refusing an instrumental delivery?
Reference
https://www.sciencedirect.com/science/article/pii/S2221618915000426
https://obgyn.onlinelibrary.wiley.com/doi/pdfdirect/10.1111/aogs.13160