Birth plan help (again) - assisted delivery

[reprise]

Well, the week when my daughter needs to commit her birth plan to paper has finally arrived.

The one question with which she's still having trouble is whether to rank an assisted lady partsl delivery higher than a caesarian if grandbaby needs some help entering this world and whether she'd prefer that assistance was by forceps or vacuum.

To address a few points which are likely to arise. This is the hospital's birth plan which is drawn up for all women (including those whose labour and delivery is going to be totally medically managed) at 36 weeks. The birth plan pretty much ranks preferences from first to last for various unanticipated events which may occur during labour and my daughter understands that safety always takes priority over preference. The labour will be midwife managed unless an unanticipated event requiring the intervention of a doctor occurs.

The "model" (for want of a better word) my daughter has chosen for her labour and delivery is one of minimal unnecessary medical intervention but with a high priority on minimising unnecessary physical distress (beyond the pain of "normal" labour) to herself and her baby. In other words, she's not going to persist in labouring without assistance beyond the point at which doing so is likely to result in more extreme interventions becoming necessary.

Obviously, no-one can forsee the actual circumstances which will exist at the time an assisted delivery becomes desirable or necessary and the circumstances will determine whether there is more than one option available.

My own deliveries were boringly normal, so I'm absolutely no help at all to my daughter each time she asks me "what do you think, Mum" about this issue.

Can someone fill me in on what to consider in respect of the various options and, in particular, when a caesar might be more desirable (as opposed to more medically necessary) option than first attempting a delivery assisted by forceps or vacuum?

[CEG]

I'm just a student but I THINK that if the baby was far enough down in the birth canal to use forceps/vacuum that would be attempted rather than a C-section at that point because to accomplish the C-section they would actually have to pull the baby's head back into and through the uterus. And vice versa the ce-section would happen if the baby was not far enough descended for vacuum/forceps.

So maybe the real answer comes from what point she is at in her labor/pushing whether assisted delivery or c-section would be best for baby. I know assisted deliveries can result in an episiotomy to heal from but that would probably be preferable to healing from a c-section.

Someone please correct me if I am wrong! Best wishes to your daughter.

[reprise]

Oddly enough, this came up at antenatal classes (which were right before DD's antenatal appointment) yesterday and the midwife who was taking the classes made it very clear that which option is taken has as much to do with the preferences of individual doctors as it does to do with anything else. She also said that when it's anticipated that a forceps delivery is going to be difficult and that a caesarian will probably have to be done anyway they generally attempt the forceps delivery in theatre with the epidural and everything else already in place so that they can go straight to a caesarian section if necessary without any delay.

At this particular hospital, apparently episiotomies are almost routine with forceps but relatively uncommon with vacuum deliveries (but this may reflect the practises of the different doctors).

[Fiona59]

Stay away from the forceps if possible.

Had one once. Never again. Took longer to get over than a C-section. Find out if they are talking high forceps or just forceps. If they need high then she might as well have a section for the damage it causes.

Now don't all tell me you've never seen a high forceps or they are a thing of the past. There not depending on where u live.

I'll never forget the young women I looked after that had 4th degree tears. Nasty, needed corrective surgery, all so the hospital could keep its section rate down.

[reprise]

Stay away from the forceps if possible.

Had one once. Never again. Took longer to get over than a C-section. Find out if they are talking high forceps or just forceps. If they need high then she might as well have a section for the damage it causes.

Now don't all tell me you've never seen a high forceps or they are a thing of the past. There not depending on where u live.

I'll never forget the young women I looked after that had 4th degree tears. Nasty, needed corrective surgery, all so the hospital could keep its section rate down.

I do know that none of the hospital doctors do rotational forceps (the midwives seem to regard the couple of private obs who still have the knack of doing these as fossils). I also know that the policy is to do a routine episiotomy for all forceps deliveries (which seems to be at odds with some studies I've read which suggest that women are more likely to experience severe tears during a forceps delivery if an episiotomy has been performed).

The episiotomy rate is pretty high at this hospital (around 60% for first time mums), although the epidural rate is quite low (70%, which is pretty good (although a little artificial as it's nor a tertiary level unit and some patients get transferred with bub in utero if major complications are anticipated).

Standard practise seems to be to suture 2nd degree and above, although the midwives maintain that there are plenty of 2nd degree tears which would heal just fine (or even better) without sutures.

The particular midwife who will be attending my daughter would intimidate even the most arrogant consultant and I suspect that no unnecessary intervention slips past her, so DD is reasonably confident that if her midwife says "honey, we need to get some help here" it's not simply a CYA decision.

[Mermaid4]

Obviously we try to avoid ANY sort of unneccesary intervention, but if it is between forceps or vacuum, the vacuum is less dangerous in most cases..Have your daughter interview her provider and ask which intervention they prefer and why. I have used both ( that is, been present with both), and have not found any more problems one way of the other. We rarely use either unless necessary...Some of the plans I have seen lately mention that while they are aware the staff , on occasion, must resort to some interventions, the couple prefers the least invasive and that the medical staff, both doctors and nurses, be up front with them with regard to explanation. Some if not all of the issues you mention should be covered, or at least asked about in the doctors office before your daughter ever gets close to labor and delivery...

[Mermaid4]

We don't do High forceps..If forceps are required they are low forceps and then, only one attempt.

[reprise]

Obviously we try to avoid ANY sort of unneccesary intervention, but if it is between forceps or vacuum, the vacuum is less dangerous in most cases..Have your daughter interview her provider and ask which intervention they prefer and why. I have used both ( that is, been present with both), and have not found any more problems one way of the other. We rarely use either unless necessary...Some of the plans I have seen lately mention that while they are aware the staff , on occasion, must resort to some interventions, the couple prefers the least invasive and that the medical staff, both doctors and nurses, be up front with them with regard to explanation. Some if not all of the issues you mention should be covered, or at least asked about in the doctors office before your daughter ever gets close to labor and delivery...

Like most women in Australia, my daughter doesn't have an ob. Unless something goes wrong there won't be a doctor involved in her delivery at all, and if something does go wrong it will be handled by one of the obs who is on duty at the time (high risk women do see the hospital obs regularly throughout their pregnancy, but low risk women see them only twice and those visits are more of a formality than anything else). The midwives have pretty much confirmed that individual doctors have their own preferences and that it's pretty much a crap shoot whether you'll get a doctor who prefers forceps or one who prefers vacuum.