Blog dedicated primarily to randomly selected news items; comments reflecting personal perceptions

Monday, June 18, 2018

New Life, Old Problem 

"[The increase in trauma rates] suggests that the safety of the procedures is declining in Canada, especially after forceps use."
Newly-published UBC study negative on forceps deliveries

"When I put my forceps on I'm 99 percent sure I can get this baby out."
"The problem of doing a C-section after pulling the baby down to the opening of the vagina is also very challenging as well, and fraught with difficulty. A lot of OBs [obstetricians] will actually favour forceps because they know they can get the baby out."
"There's also a tremendous patient satisfaction with a vaginal delivery as opposed to C-section."
"We do need a measured response here, as opposed to just abandoning these procedures."
Dr. Christopher Ng, Department of obstetrics and gynecology, University of British Columbia"

"[Women should ask about risks and benefits of all modes of delivery] so they have time to digest what those risks mean to them."
"Women are very angry when things like this [trauma to new mothers and newborns] occur to them and they haven't been informed about how frequent [sic] we know it occurs."
"These perineal lacerations or tears that we are seeing, those accounted for 87 per cent of the cases of obstetric trauma among women who had forceps or vacuum deliveries in our study. Those aren’t anything to scoff at. These cause long-term quality of life implications such as having severe perineal pain or sexual dysfunction or abscess formation. Perhaps the most disabling complication from these lacerations is an inability to control your bowels or your bladder."
Giulia Muraca, post-doctoral lead author, study, University of British Columbia
The rate of obstetric trauma during operative vaginal deliveries jumped from 16.6 per cent in 2004 to 19.4 per cent in 2014 for first-time mothers, according to the study. CBC

The just-published study out of UBC points out that the most common injuries to women following forceps or vacuum deliveries turn out third- and fourth-degree perineal tears. Far less frequent, albeit the most common harms to babies included brachial plexus injury, damage to the nerves that come from the spinal cord in the neck and travel down the arm. Higher rates of injuries to mothers and babies are being seen in forceps and vacuum assisted vaginal deliveries.

The recent study published in the Canadian Medical Association Journal is the second turned out by this same team out of UBC which shows higher rates of injuries to mothers and babies in forceps and vacuum deliveries. The UBC-led team reported last year rates of severe birth trauma five to ten times higher in mid-pelvic deliveries where the baby's head is stalled midway through the birth canal. The study looked at close to two million one-baby deliveries in Alberta, Saskatchewan, Manitoba and Ontario in the years 2004 to 2015.

There was an increase among first-time mothers suffering physical injuries, from severe tears and lacerations to injured pelvic organs, joints and ligaments. Women with a previous C-section over the study period were similarly prone to suffering these injuries. The increase, however was most concentrated among "operative" vaginal deliveries; forceps and vacuum-assisted births. The largest trauma increase involved forceps deliveries, at a rate of 19.4 percent in first-time mothers in 2004 that saw an increase to 26.5 percent in 2014.

The conclusion is led by the understanding of concern over rising C-section rates, resulting in doctors being urged to consider forceps [or vacuums] when labour fails to proceed smoothly. These delivery options are considered to be safer than C-sections. Ironically, it is the thrust to lower the number of C-sections performed in delivery that has resulted in the once-common use of forceps by doctors skilled in their use, being used far less frequently currently by doctors who have familiarity with forceps skills.
forcep deliveries

Trauma to babies increased as well among first-time mothers, from 4.5 to 6.8 per one thousand deliveries over the period being studied. Doctors themselves admit to dwindling skills and lack of training in forceps use. A greater number of babies being delivered via C-section [equating to a third of all deliveries at the present time] leaves fewer opportunities for medical graduates to be taught correct and safe forceps usage.

A mere half of graduates of an American residency program, according to a 2007 study, felt competent in the use of forceps. Australia has seen recommendations to ban the use of forceps during deliveries completely, while some U.S. hospitals already prohibit forceps use. Malpractice lawsuits reflecting babies injured through forceps deliveries in Canada represent another consideration. An Ontario court awarded a family $2.8 million, finding a gynecologist negligent in the use of forceps in a delivery resulting in catastrophic brain injury to the newborn, in 2012.

The baby had suffered 'profound' asphyxia when the forceps caused umbilical prolapse when the compressed cord cut off blood supply and oxygen to the fetus. Used properly, forceps make for faster post-birth recovery with new mothers able to leave hospital the day following birth. Forceps have the appearance of a pair of metal salad tongs, while vacuums resemble and operate like a suction cup, both in use when concerns arise relating to the birthing mother being unable to push the baby out of the birth canal, the baby is stick there, or the fetal heart rate is concerning.

Since there are fewer forceps or vacuum delivery procedures being performed, with that type of delivery accounting for only 14 percent of all vaginal deliveries in 2014 in Canada, new doctors are not being exposed to real-life training with forceps, to the detriment of confidence and technique. As reliable instruments developed in the 17th Century, they have more than proven themselves over time but the vital confidence and skills in their use are being lost.

On the other hand, the universal concern over the part they play in vaginal deliveries when required, has spurred some action, with studies from the United States pointing out the value of simulation training's role in improving outcomes for mothers and their babies.

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