What are Instrumental Deliveries

Wendy Turner-Webster: Every woman wants a natural and smooth birth for their child. However, for some mothers this isn’t always possible without medical intervention. Dr. Maggie Blott from the Royal Victoria Infirmary in Newcastle Upon Tyne is here to talk about instrumental deliveries. Hello there! Dr. Maggie Blott: Good morning! Wendy Turner-Webster: Now, just take me through the various options in instrumental deliveries. What are they? Dr. Maggie Blott: Well, this is a process whereby we deliver the baby for the mother and there are two main instruments that we use. One is forceps and the other is a ventouse. Now, forceps are probably what people are most familiar with. They are a metal instrument. They look rather like two spoons and they fit around the baby’s head like that, and allow us to put some traction on the baby to deliver the baby. The other instrument is something called a ventouse and that’s a suction cap and it sits on the back of the baby’s head. It can wither be metal or it can be silastic plastic. And it creates a vacuum underneath the suction cap and again we can pull on that, cause some traction and deliver the baby that way. The choice of instrument will depend on the situation. There are some times where the ventouse is a better instrument and there are some times where we need to use forceps because of the situation you have in front of you. Wendy Turner-Webster: Okay, well let’s about those and say take the forceps first, what situation would the mother be in that you feel this intervention with forceps in particular is necessary? Dr. Maggie Blott: Yeah. We use instruments to deliver babies either because the mother is tired and she can’t push her baby out or because the baby’s heart rate is dropping, and the baby is getting into distress and needs to be delivered quickly. The situation where the mother is tired maybe exacerbated or made worse by an epidural. And sometimes particularly if you’re having your first baby and you can’t push your baby out, and you can’t help the doctor to push the baby out because you’re tired and you have got an epidural, we tend to use forceps in that situation because we can exert slightly more traction, we can pull slightly harder. These instruments are designed to protect the baby. It sounds quite— Wendy Turner-Webster: Yes, it sounds very fierce, doesn’t it? Dr. Maggie Blott: It does. But actually they are designed in a way that actually protects the baby as you’re doing the procedure itself. So if you got a mother with an epidural particularly if it’s her first baby, you may choose to use the forceps in that situation. Also, sometimes the baby’s head turns in a funny way. Babies have to born looking down with this bit of their head coming first. And occasionally, the baby will be lying in the birth canal looking sideways or indeed looking up at the ceiling and in that situation, you have to turn the baby around and then deliver it. And we can -- there is a set of forceps that we can use to do that to turn the baby and deliver the baby. Wendy Turner-Webster: I’m sure that it might be a natural concern to think that this instrument, these forceps are somehow going to harm the baby’s head. Dr. Maggie Blott: I mean there are, they need to be used carefully and doctors need to be very well trained to use them. So we don’t allow doctors to do instrumental deliveries with forceps or indeed with the ventouse until they’ve been fully trained to do it. Having said that, there are some effects on the baby, particularly bruise marks on the baby’s face is very common when you have had a forceps delivery, the baby’s have some bruising across its cheekbone. Wendy Turner-Webster: Yes. Dr. Maggie Blott: That’s because, that’s one of the pressure points. Now those bruises are usually very minor and they will go very quickly. Within 24-48 hours those bruises will have gone. Wendy Turner-Webster: Yes, my first baby had to be whipped out with forceps in the end. Yes, he had these little quite distinctive marks but they did go very quickly. Dr. Maggie Blott: Mothers are concerned about obviously parents worry about too. Wendy Turner-Webster: Any blemish you get concerned about. Dr. Maggie Blott: Absolutely right. Yeah, so they do -- we do reassure them that they will settle down very quickly and of course it does. Forceps are actually very safe for babies. You get far little problems with forceps than you do some times with the ventouse. Wendy Turner-Webster: Now in what instance would you give the ventouse? Dr. Maggie Blott: Well, the ventouse is the instrument of choice now. The majority of women who have an assisted delivery will have a ventouse. That’s because it’s gentler for the mother and it’s much easier for the mother, and of course there are very few problems with the baby. The ventouse sits on the baby’s head like this and creates a vacuum. So when you pull on that, when the babies are born, they’ve got this bump here on the back of their head which -- actually those are quite alarming. But again it’s completely normal. It’s designed, the instrument is designed to work like that and you really spent a lot of time reassuring parents that bump will go. But it’s an easier instrument to use and it’s safer for the mother. You get much less internal tissue damage, tears and the like if you use a ventouse. So in the majority of cases now, if you have to have an instrumental delivery, the ventouse will be what the doctor uses. Wendy Turner-Webster: I’m assuming that the baby’s head isn’t obviously not fully developed, is it yet? So again, there would be the concern these instruments sort of instructions and especially the suction one -- Dr. Maggie Blott: Yeah. The baby’s head is designed for labor. The bones and the skull is not fused, and that’s to allow some compression on the baby’s head as it descends through the birth canal without damaging it. So the head is designed to be molded and that’s why we can use the ventouse cup safely, because we know that the baby’s head is designed to be molded slightly, because of the process of labor. And therefore we can put suction on the head, have some bump on the baby’s head that will settle very quickly after birth. In fact, the bump goes within about an hour usually and you’re left with just a little bruise on the back of baby’s head, which is again alarming but with reassurance people don’t worry about it. Wendy Turner-Webster: What kind of pain relief is necessary in an instrumental birth? I mean, presumably quite a high level. Dr. Maggie Blott: Yes, particularly if you’re going to use forceps. Forceps are quite big relatively speaking and do broaden out the birth canal, the vagina quite a lot. It can be uncomfortable. So we try and use a pain relief in that situation. Now, a lot of women who need the forceps delivery have got an epidural already, so we top up that epidural, make sure they’re pain free and deliver the baby. If they haven’t got an epidural, it depends on the speed with which we need to do the delivery. If the baby is acutely distressed and we need to deliver the baby very quickly, we can use local anesthetic in the perineum which is the skin just at the edge of the vagina and we can put local anesthesia to the vagina, soften down as much of that area as possible. And then we could deliver the baby very quickly and sometimes we do need to deliver babies very quickly because they are in acute danger. If we’ve got time to put in an epidural before we do an instrumental delivery, then we’ll do that. So if you’re doing that because the mother can’t push her baby out or because there is a possibility we may not succeed in doing the instrumental delivery. We have to do a caesarian section, and then we’ll put an epidural in. Wendy Turner-Webster: What happens in the kind of situation where a mother comes in and has elected not to have any pain relief? What really, by the time it gets to an instrumental assisted birth is that going out of the window? Dr. Maggie Blott: It can be extremely difficult. Women who didn’t want pain relief have been up in about in labor, mobilizing and then cannot push their baby is out or their babies become acutely distressed, we need to deliver the baby quickly. It can be very difficult and it can be a very painful experience for some women. We try and avoid acute pain like that for women. But we don’t have time sometimes. We always have the option of putting in an epidural or a spinal which is sort of quick form of epidural if we can. Wendy Turner-Webster: What’s the rate of recovery after an instrumental birth for the mother? Dr. Maggie Blott: Yeah. It depends on what type of -- people will recover better from a ventouse delivery than a forceps. And that’s partly because we need to do episiotomy with the forceps. Episiotomy is a cut into the perinea, the skin at the entrance of vagina and we always need to do that with the forceps delivery. And the episiotomy is stitched up afterwards and can be very, very painful for the first two or three days after birth and we will need pain relief for that. And actually the pain from the episiotomy takes seven to ten days to go and even after that you are left with discomfort in that area for up to six weeks. So it doesn’t feel completely normal for at least six to eight weeks and sometimes a bit longer after the baby’s been born. Wendy Turner-Webster: Of course, any mother who has been through that will know how it will affect your sex life and stuff continuing from that? Dr. Maggie Blott: Yeah, it’s normal. I should say, it’s normal for you to be uncomfortable for at least six weeks and particularly if you’re breastfeeding because if you’re breastfeeding your levels of estrogen, female hormone are low and the vagina takes longer to recover. So in that situation it could take six, eight, 10, 12 weeks before women feel comfortable having sex again. And it is important that they know that because most of the women get very distress. They think by six to eight weeks they should be back to normal and in fact they’re not, and they get very distressed by that fact. So explanation and discussion before they go home from hospital is an important part of the process of their forceps delivery. Wendy Turner-Webster: Because yes, you can imagine, if somebody hasn’t actually been prepared or gone through all these things, if you suddenly confronted with forceps or the ventouse that can be very scary. Dr. Maggie Blott: It is. Wendy Turner-Webster: It’s all the expectation of birth, isn’t it? Dr. Maggie Blott: They look terrifying and people don’t know where they are because they haven’t seen them used before. So they are frightened and then their husbands are frightened and some women can be quite traumatized by it. It’s important part of the antenatal preparation class that things like forceps are discussed, so that you know why you might need the forceps. You know the person who is involved, you know that you’ll need episiotomy and need to have a cut down and you know it’ll take longer to recover that. If you’re told that before it happens, then you will understand what was happening to you and you’ll recover from it. Child birth classes tend to focus on normality. The normal -- and of course the majority women will deliver normally. In those situations where you can’t, you need to be prepared for it. Wendy Turner-Webster: Do you find that women will come in and obviously having the baby and you’re surprised how little they know? I mean all we are as prepared as we like to think we are. Dr. Maggie Blott: I don’t think we are. Very few women have any experience of child birth. In the old days, 100 years ago, you would have seen your sister being born, you would have watch your sister having a baby, you’d been there at birth. By you birth time you are going to have your own baby; you’ll have had quite a lot of experiences because a lot of babies of course are born at home. Nowadays, our only experience of child birth is either watching something on the television which is not always based on reality or when you have your own baby. So people find it a very awesome experience and people -- a lot of women dread going into labor because they’ve no idea, no thought, no idea really of what is going to be like and people worry a lot, and I think that’s because of the way the current culture of child birth is developed in the later 20th century, and 21st century. Wendy Turner-Webster: With an instrumental delivery, have they increased over the last few years? What’s the – do you know any sign of percentages or anything? Dr. Maggie Blott: Yeah. The average instrumental delivery rate is run into about 13 to 15%. So when you come into hospital, you’ve got about a one in eight chance of having an instrumental delivery. I think the rate is going up a bit because women have got epidurals a lot more and of course epidurals do tend to increase the instrumental delivery rate. People don’t know that the second stage of labor can actually take a long time, it can be completely normal. You’re having your first baby, you just have to push for two hours. Nobody tells you that, you don’t realize that actually the process of pushing your baby out can’t be prolonged and women lose heart. They feel they can’t do it. They get tired and they just give up. What we need to is we need to educate women more about the process of labor. The fact that it will take you two hours to push your first baby out and that is normal. And to get midwifes really up there and encouraging women to keep going, to keep pushing because they will have normal delivery if they keep trying. Wendy Turner-Webster: As an Obstetrician, do you mind that the rate is going up in instrumental birth and it’s going up because more people are having epidurals? Dr. Maggie Blott: I would. Wendy Turner-Webster: Is it a problem or not? Dr. Maggie Blott: Well, I would prefer women to have natural and normal labor as possible, because I know it’s better for them and it’s certainly better for their babies and they will recover better. So I do worry that our intervention rates, of which instrumental delivery is one, are going up. And I think that we need to work quite hard with our midwifery colleagues to try and reintroduce the idea of normality. We’ve have really medicalized birth a lot in this country. It’s not a medical event, it’s a normal event and we need to spend a lot of time telling ourselves that and of course and reassuring women about that so that we can increase on normality rate. If you increase epidurals, if you go on having to do more and more instrumental deliveries, you will end up increasing your Cesarean-Section rate and we know that there are complications with Caesarian-Section which we have to try and avoid. Wendy Turner-Webster: Is it making a difference that the lack of midwifes available at moment? Dr. Maggie Blott: There is certainly shortage of midwifes and shortage of obstetricians, and of course one of the things we know is that women who are well supported in labor, who’ve got one to one care, one to one midwifery care, midwifes in the room within the whole time supporting them, talking to them, encouraging them, their rate of interventions will be a lot lower than the woman who is left in a room. The midwifes -- the labor with shortage of midwifery staff, the woman will be left on their own in labor, that they have their birthing partner, husband who is often more terrified than they are actually or they have friend with them, they wouldn’t have that support from professional and the reassurance from a professional. I think people ask for interventions sometimes because they’re frightened. Wendy Turner-Webster: Yes, yes. Is there also a school of thought that says that hospitals are more keen to do sort of caesarians and instrumental births to get the baby out because now we’re in a compensation culture, that you might be sued or if the least little thing goes wrong, does that play a part? Dr. Maggie Blott: Certainly, it plays a part. I think in some people mind but I don’t think it’s the reality of what happens. I don’t think we go and deliver babies because we’re worried that we are going to be sued if we don’t. I don’t think. So I think what’s happening then, it is because we’re very medicalizing, we’re monitoring women in labor, we’re picking up more potential problems and then we’re intervening and I think it’s that we just have to stop us roller coaster which leads to instrumental deliveries and the problems associated with them. Wendy Turner-Webster: I wonder, if we should just perhaps, wrap it up on a positive note and as much as instrumental births are nothing to be scared of. Dr. Maggie Blott: Yeah, they’re not. The majority of births are done, instrumental births are done because you and your baby have a problem. And when you think about the alternative which maybe a baby that’s damaged because it’s can’t be born quickly, and of course instrumental delivery is a very safe. And be reassured, because the staffs that are doing your instrumental delivery will be well trained to do them. Wendy Turner-Webster: Lovely. Thank you very much for talking to us. Dr. Maggie Blott: Thank you.