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Forceps and Ventouse

Forceps and Ventouse

Author - Paul Henderson

An assisted birth using either forceps or the ventouse cup is a relatively common method of delivery in New Zealand making up about 12% of total births. That means that in the New Zealand setting there will be about 6000-7000 babies born this way every year. There are three main reasons that you may need an assisted birth. The first two: delay in second stage/inability to push the baby out and fetal distress are the most common with the first being the main reason by far. The third reason - the avoidance of pushing in second stage (usually as a result of underlying heart disease) is very rare.

Are there any ways you can avoid an assisted delivery. Certainly by having an actively managed labour and adopting upright positions in labour will help to avoid assisted delivery but probably the best way is to avoid an epidural. This is easier said than done and pain relief requirements in first stage will usually have precedence in your thinking before how the baby will be born. For many women it is an acceptable trade off i.e. to have an assisted delivery with good pain relief through labour. If you do have an epidural in second stage you should be allowed plenty of time to push the baby out: up to three hours in the case of first time mums. Sometimes Syntocinon should be used in second stage to increase the likelihood of a normal birth.


Forceps:

Forceps.jpg


Forceps are smooth metal instruments that look like large spoons or salad servers. They have been designed to fit the contours of your vagina and to fit safely around the baby's head. Rotational forceps which were designed to rotate the baby's head in the vagina are now considered obsolete and they have been abandoned in favour of the ventouse cup. Usually an episiotomy will be required to help deliver the baby. Usually an epidural is needed for pain relief during a forceps and you should insist that one is present if not in already as this will only take an additional 20 minutes or so.


Ventouse:

Ventouse Machine.jpg Ventouse.jpg


The ventouse is a small, soft plastic cup that gently fits the baby's head to help ease the baby's head out during the birthing process. It is more physiological in its approach than the forceps and is less likely to cause damage to either mother or baby during delivery. One of the reasons that it is safer than forceps is that the cup will detach from the baby's head if too much traction is used. Due to its much less invasive nature an epidural is not always required when using the ventouse. Metal cups are falling out of favour and in good hands the soft plastic cups should be used in preference.


The Downside:

The main problem with either forceps or the ventouse is the damage both can cause both to mother and less likely to the baby. A third or fourth degree tear ( where the anal or rectal muscles are damaged) can occur in 4% of ventouse deliveries and up to 12% of forceps deliveries. There is also evidence to suggest that long term pelvic floor problems including urinary incontinence will be more likely in the future after an assisted delivery. For the baby a small mark on the head called a chignon can occur after a ventouse. This usually disappears after 24-48 hours. More seriously a cephalhematoma can occur in the deeper layers of the scalp but again this does not usually cause major problems. Injuries from forceps are rare but because of the greater force used can be more life threatening.

Forceps and Ventouse: The Expert View

This is one aspect of childbirth where the experience of the operator is critical. Having a junior Registrar perform the task is sometimes an invitation to disaster as they often lack the critical judgement skills to perform a safe and yet patient friendly delivery. Because for both midwife, patient and doctor the focus is on achieving a vaginal delivery sometimes very basic rules of patient care are set aside in a bid to avoid a Caesarean birth. The myth endures that recovery from a Caesarean is harder than from a difficult forceps delivery. Ask any woman who has experienced both and she will answer categorically that recovery after forceps was infinitely harder. I think caregivers of women in labour need to develop a healthy awareness of exactly what they are trying to achieve with their patients. To avoid a Caesarean Section( CS ) at the expense of major vaginal trauma and a very damaged psyche does not seem a worthwhile goal and yet that is precisely what happens on a daily basis in most New Zealand birthing units. Often there is retrospective justification for performing difficult instrumental deliveries claiming that as long as baby and mother are healthy the procedure has been successful. What this fails to appreciate is that the woman may have suffered very real psychological damage during the process.

Forceps were first invented in the 17th and 18th centuries and marked a very real advance in Obstetric medicine. By enabling caregivers the ability to deliver vaginally babies that were previously unable to be, forceps saved lives - particularly mothers. These women had often succumbed after extraordinarily long labours that lasted, in some cases, for days. Forceps became life savers.

With the advent of the Caesarean Section the need to perform very high difficult forceps that often led to the demise of the baby disappeared. Caesarean Section remained a hazardous procedure however until the mid twentieth century when advances in anaesthesia, antibiotics and blood transfusion meant that it eventually became a very safe procedure. The persistence then of forceps as a method of delivery is perhaps historical due to the perceived notion that it was safer than a Caesarean Section. In 2012 with a Caesarean Section almost as safe as a vaginal birth perhaps it is time to re-examine the place of forceps and ventouse in modern Obstetric practice.

It is important at this stage to distinguish between the two types of assisted delivery. One of which should definitely remain in common use in delivery suite the other I have serious questions about! These two types of delivery relate to where the baby's head is when the forceps or ventouse is applied: the outlet delivery and the low mid-cavity delivery. In the former the fetal head is generally visible and the ventouse or forceps is used really to guide the baby out. No-one would question this type of delivery and generally there is minimal trauma involved. An episiotomy may not be required. The other type of delivery though needs to be questioned by modern Obstetric practitioners. Where significant traction is required or manipulation of the fetal head is needed caregivers need to ask the question: Is this preferable to a Caesarean Section?

What you need to ask your LMC if you are about to have a forceps or ventouse?


How many of these procedures has the practitioner performed?
If the answer is less than 100 then insist on getting someone who is more experienced. This is not quite so vital for outlet type deliveries.


Is the fetal head visible and if not can I opt to have a C Section?
This is a legitimate question to ask. If you still feel confident to proceed insist on decent pain relief which generally means an epidural. If there is not absolute confidence that the baby will deliver easily insist on the procedure being performed in theatre so that a C Section can be done instantly if problems arise.


Do I have the choice between ventouse or forceps?
Paradoxically although easier to attach to the baby's head the ventouse, especially the plastic cup, demands a higher skill level and therefore junior Obstetricians will either opt for forceps or the metal ventouse cup. Insist they use the plastic cup or find someone who is comfortable with its use.


How many times are you going to pull on the baby's head to achieve delivery?

A simple rule of thumb is that after 3 attempted pulls if there is no descent of the fetal head onto the perineum the delivery is unlikely to be successful. Insist that the Obstetrician stop trying if delivery is not occurring after three pulls as this may put the baby at risk.

Above all, be assertive. Take control of the situation and ask to be informed of what the alternatives are. This is your birth and your baby and you have every right to demand what type of delivery you will have.


Author Bio

Paul Henderson.jpeg

Paul has been practising in both Private Practice and at North Shore Hospital since 1996. He has lived most of his life on the North Shore of Auckland. Paul completed his Medical Degree in Auckland and trained in Obstetrics and Gynaecology in New Zealand, the UK and South Africa. He is a supporter of Midwifery and was instrumental in setting up Kate Sheppard Midwifery in Albany, Auckland.

Paul sees the internet as the future of the birthing industry and sees social networking and net-based education as tools to enhance patient education and provide informed choice.


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