Monday, 28 July 2014

dealing with perineal trauma

Human's don't seem to be very well designed for giving birth.  Those big brains just use up too much space - babies heads are too big, and it can cause trouble downstairs.

Women are MUCH more likely to need intervention for a first pregnancy than for subsequent pregnancies. This is probably down to a combination of an unstretched pelvic floor and the scariness of going through birth for the first time.

We've all heard that there is a rise in ceasarian rates, and if you look at the statistics it is plain to see that the number of caesarians is rising, while the number of births assisted by forceps is dropping.  With all the caesarians, doctors are getting a lot of practice doing them, and they are safer than they've ever been.

Some types of forceps deliveries - the ones that carry the greatest risk of damage to mothers and babies - using Kielland forceps (sometimes called rotational forceps) high in the birth canal to turn the baby during vaginal delivery are now used so rarely (and with good reason), that in many hospitals they have been phased out altogether.  See this NCT research article for more on this.

The more usual kind of forceps delivery involves inserting two long metal spoon shaped things either side of baby's head. The two are then connected together, and someone who is trained and skilled in using forceps will help to pull baby out while mum pushes. To bring the baby out with forceps the 'birth canal' needs to be widened, by a cut, called an episiotomy.  

They medical professionals use the episiotomy cut to avoid your body tearing along the most easily available line, because nobody wants a tear extending to the back passage.

The trouble is, although a bad tear is really bad, it can be harder for your body to recover from a cut like an episiotomy, than from a minor tear. It took me a lot longer to recover from the episiotomy I had for my first birth (using forceps) than the emergency section I had for my third. And I'm not the only person who has had that experience.

You need to give informed consent to have a forceps assisted delivery, and yet, in the moment, many women feel that this is lacking. And also, befuddled and exhausted, women find themselves agreeing to things they don't really want.

L summed it up nicely: 
I said no forceps ... and [my daughter] was literallty hauled from me with them.
C said:
I ended up having to have an epidural, which I vowed never to have. After a very slow induced labour the consultant decided enough was enough and used forceps. I felt like i could have carried on pushing and begged the consultant not to intervene but they said I was running out of time (even though the baby's heart rate was steady). All in all I was left feeling like I'd lost control and was saddened by the whole experience.
I had said I didn't want forceps as well, but 48 hours after my waters broke, with my baby showing no sign of distress, the health professionals were insistent that I needed to get the baby out. I agreed to being induced, which speeded things up a lot, but meant I had to be strapped to a bed to be monitored. I really wanted to move around, but couldn't, and sitting on the bed was very painful. I felt like baby couldn't get out with me on my back, but I wasn't allowed to move. I felt that I was threatened with a section, and offered forceps as my only other choice.  What should have happened is that I should have been allowed to get up and move about, and properly informed that if I agreed to being induced that wouldn't be allowed. However, that all didn't happen, and I agreed to the forceps, and as a result I had six months of not being able to sit properly, two years and another baby before I lost the discomfort altogether. The baby himself was bruised, but healthy.

It could have been worse. L is still seeing a consultant about problems caused by forceps 9 years ago. She was not given an episiotomy, and tore badly, although she had no problem recovering from an emergency section for her younger daughter.

Perineal trauma isn't just a problem for forceps delivery. It can happen in 'normal' deliveries too. Minor tears are fairly common, and if it looks like a woman is at risk of a major tear health professionals may give an episiotomy. D didn't have a forceps delivery, but was given an episiotomy during labour. She said:

I didn't have forceps but did have an episiotomy which I was just informed about as it was being done! I was iron deficient and it took a long time to heal.
There's a chat over on Mumsnet about forceps vs caesarian, on which a few people recommend going straight for caesarian, because the risks of other interventions aren't worth it. Personally, I always liked to hope for the best, meaning a vaginal delivery with no intervention. I got it once, and was walking to a friend's house with my new baby the next day.  It is something every pregnant woman should consider for themselves, but with a full understanding of possible outcomes.  

There is a good article on episiotomies and tears here if you'd like more information.

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