Amy being interviewed for ABC TV

There has been some heated debate recently about a headline grab that followed an interview of Amy Dawes, co-founder of The Australasian Birth Trauma Association (See link to the website here.) by ABC News. By her own admission, Amy is regretful that she answered yes when asked does she think that forceps should be banned? She herself has written that she was nervous and jumped in without necessarily thinking about the bigger world-stage picture. See below about why this is important. But this isn’t Amy’s fault and it isn’t the reporter’s fault. I think the fault lies with the lack of consideration given to women being able to deal with information, with facts, with evidence. And with our propensity to make childbirth mysterious and view it through rose-coloured glasses.

Amy is a mum (therefore a consumer- a non-medical person) who has suffered (for the rest of her life) a birth trauma to her pelvic floor muscles. Amy wasn’t informed during her pregnancy about the risks or the benefits of forceps. So when it came to making an informed decision during her prolonged labour, when the doctor said- the baby will come out with either forceps or a caesarean – because of her ignorance about the risks of forceps, whereas she was fully informed about what is involved with a Caesar and the risks of having a Caesarean section – for her it was a no-brainer.

Avoid the Caesar at all costs.

And what happened? Amy suffered a bilateral levator avulsion injury to her pelvic floor muscles from forceps. This happens around 40% of the time forceps are used. (It also happens in around 40% of women over the age of 35 when they are having their babies). These statistics surely warrant a mention during the 40 week pregnancy. If it was a hamstring tear or a biceps injury that happened 40% of the time when you undertook a certain activity, I am pretty sure we would be warned about it.

We live in a very regulated country – we have lots of rules and warnings in Australia. We can’t smoke on beaches (yay) or in restaurants (double yay), we have to wear seatbelts in cars because the evidence tells us that we sustain more significant injuries in big car crashes if we don’t wear our seatbelt. We have to swim between the flags so we don’t drown and can’t be served any more alcohol when we are already drunk (triple yay). The bar attendant and the establishment that it happened at are fined very substantially for doing so.

Public Intoxication Assessment Tool

A clear assessment tool for assessing drunks (NZ) 

I included this because its such a clear infographic on assessing the state of sobriety

Rules for serving alcohol in Australia

And yet, many women do not hear anything about the risks of a vaginal delivery and the potential serious changes to the quality of their life if they sustain a serious injury with a vaginal delivery.

If we have any surgery, especially gynaecological repair surgery, we have to sign a consent form saying we understand what can go wrong during that operation. I have written a blog before though about the lack of insight we truly have about what we are signing for, when signing consent forms for operations. It’s a lot like when I sign forms for the bank – I don’t give them the consideration they deserve. Patients sign the consent form and then get surprised when they start to leak after an incontinence procedure (the consent form will say your stress incontinence will improve but you may get overactive bladder symptoms post-op and leak on hearing running water or putting your key in the door) or their prolapse repair surgery fails (even though the consent form may say if you have bilateral levator avulsion your risk of failure may be up to 80%). (NOTE: READ AND UNDERSTAND YOUR CONSENT FORM PROPERLY).

But when we have babies, there is still no informed consent form and yes I understand that many women are in no shape at the stage of needing forceps, to fully comprehend what the implications of a vacuum versus forceps versus a Caesarean section are. But sometime through that 40 week pregnancy, surely there can be a run through of what might happen, so the woman and her partner can appraise the risks and make a reasonable decision about what she would like to do should difficulties arise. That can always change at the last moment. But the story I hear every day from patients who have suffered a traumatic vaginal delivery is- ‘Why wasn’t I informed something like this could happen? I may well have still have chosen not to have a Caesar, but I would have made the decision based on the knowledge I had acquired through my pregnancy, from my obstetrician’. This information would have been unbiased, evidence-based information. The information is there – there are tools even to look at your risk dependent on certain factors such as your ethnicity, your height and weight, your age and other measurable factors (called UR-CHOICE).

One of my physio colleagues who attended the most recent Urogynaecological Society of Australasia (UGSA) reported there was a presentation entitled ‘Informed consent for vaginal birth’. This is a great thing (albeit weirdly late in the history of womankind and childbirth).

The discussion was that women should be fully informed regarding:

1. Risks of pregnancy eg. eclampsia/ premature birth etc

2. Risks post partum eg. haemorrhage/ infection,

3. Risks of delivery including elective C-section and repeat C-section

4. Risks of planned vaginal birth including risks of spontaneous delivery or foetal distress etc leading to instrumental delivery or emergency C-section.

5. Future risks from all methods of delivery is important to be known.

There was a consensus that vacuum should be used instead of forceps where possible.

Vacuum                                                    Forceps

Unfortunately there are some clinical situations where vacuum delivery is not suitable. There is concern that if the literature includes statements saying forceps should never be used, then women in low resource countries will suffer, as vacuum is not usually available there and an emergency C-section will occur which puts the women at risk of death. If a woman has obstructed labour and the baby is already dead, a vacuum cannot be used as the scalp of the baby comes off. Caesars can be dangerous in cases where the surgeon is inexperienced. Obstetric anal sphincter injuries  (OASIS) are also a risk factor with vaginal deliveries. Doctors who work around the world in low-income countries (where the majority of babies are born) report that there are definitely circumstances where forceps must be used.

Forceps are often used to assist in delivery of the baby’s head at time of Caesarean section. If registrars are not familiar forceps during a C-section, then more injuries may occur. That is what apparently happened with the vacuum in its early days – lots of injuries previously and now there are vacuum extraction training workshops. There can also be injuries from vacuums-fistulas from vacuum, injuries to the cervix and vagina with vacuum misapplied. Also the vacuum is contra-indicated with the delivery of premature babies. In many low-income overseas countries, forceps are also required because vacuums are too expensive.

It is risky if overseas doctors read articles like these on the internet (the one saying ban the forceps as a headline), and they then will not use forceps and don’t have vacuums and will do a Caesarean section – even for a baby who has died during delivery.  Many maternal injuries may result from a lack of use of forceps – Caesarean sections causing bladder injures, ureteric injuries, horrific uterine and cervical injuries (so much so that the women most likely will not be able to have any other children) – and she has only delivered a stillborn baby. But because the baby has died during the prolonged labour and has been there in the birth canal for 3-4 days, there is compression of the tissue and it becomes ischaemic and dies leaving a fistula. She will then leak urine +/- faeces uncontrollably through the vagina and be ostracised by her family and community…. but because of the C-section performed she will have an intact pelvic floor but no more children.

So obviously there is more to the story on the use of forceps.

My wish is there could there be a more moderate conversation about forceps because of their life-saving properties as you have read above. But there is no doubt that there is disparity between Australian states in the rates of use of forceps and the question is whether this relates to the health departments of the various State government dictating the % of each type of delivery because more Caesars cost more money.

Is it possible to have an informed debate without it becoming inflammatory and emotional?

I believe many women actually are more incensed about their lack of information prior to the delivery about what might happen. We are living in an information society – there is so much information available now via the internet, women are incredulous that they have never heard of prolapse or birth trauma before they have lived it! Where does that come from? Is that related to a suppression of negative talk about childbirth maybe from health professionals such as midwives and obstetricians – with good intentions- they don’t want women scared out of their wits before they have to deliver. I used to take ante-natal classes 20 years ago and I got scolded at the hospital for mentioning things like incontinence and prolapse to the women as it was considered too scary. And to be honest I didn’t even know about levator avulsion in those days (nobody did except a doctor in the US in 1938 who described levator avulsion in a medical text-book and it was never discussed again until many years later).

Should we still subscribe to the belief that women shouldn’t know about these things (such as levator avulsion and pelvic floor dysfunction) because it’s too scary for them? Shouldn’t they receive just as much information about what the different risks that are associated with childbirth as they do with any operation they are about to undergo? Are not women entitled to full disclosure?

Full disclosure can maybe only come with informed consent for women undergoing childbirth.

I look forward to the continuing conversations about this topic. And if you are reading this in another country or looking at the video links from the ABC story on forceps and childbirth, there is a place for forceps for sure.

And Amy Dawes is such an amazingly strong woman that following all the turbulence of this experience, Amy has gone on to co-found the Australasian Birth Trauma Association, a charity to give support to women whose birth experience was traumatic and from this many women have been helped by the information available on this website.