Dispelling the fear
There can be a great deal of mystery and fear surrounding instrumental delivery. You may have a friend who had a terrible experience and still feels traumatised, or perhaps you’ve seen pictures or videos online and are adamant that you don’t want this to happen to you.
As with all things in pregnancy and birth, you have the choice to accept or refuse any kind of intervention. What is most important is that you do this in a fully informed way. Within your birthing experience the one variable we all really have control over is the provision of information ensuring you are in a position of empowerment when it comes to making those choices and ultimately having a more positive birth experience.
At The Birth Collective, we strongly believe that the first time an instrumental is discussed, should be in the antenatal period and not at your delivery. In this blog we’ll talk about what an instrumental delivery involves, what are the reasons you may have it and what the risks are. By arming you with information, we can hold true that old adage, ‘knowledge is power’.
What is an instrumental delivery?
Instrumental deliveries are relatively common accounting for 10-13% of all births and if it’s your first baby there’s around a 30% chance you may end up with one. As obstetricians our primary purpose is to facilitate a safe pregnancy for both you and your baby and so far the most part we’ll aim to give you space for a non-interventional birth if that’s what you choose, unless concerns arise and you need help to expedite your birth.
There are two types of instruments used for an instrumental delivery, forceps or ventouse, otherwise known as a vacuum cup.
A ventouse is the name of a small hand held suction cup that is placed on the baby’s head. In the UK the most commonly one used in most hospitals is a kiwi omnicup, which is a disposable instrument. It’s made up of a small plastic cup with foam in the centre which is the part that sits against your baby’s head, it has a thin plastic tube, with measurements marked on it, which aids us in checking that it’s at the right spot and finally a handle, which also acts as a pump to create pressure. This has a handy safety mechanism, which allows your doctor to see how much pressure is being applied.
To apply the cup we gently insert it in to your vagina, we then press it against the baby’s head and when it’s in the right position, increase the amount of suction applied to help the cup to stay in place. Once we’re happy that the position is correct, we will help guide the baby’s head into a more suitable position for birth by gently pulling on the handle with each contraction while you continue to push and ultimately help you deliver. Your baby may have a small circular bruise on the top of their head afterwards, but this will disappear after a few days and may mean your baby suffers from neonatal jaundice (around 5-15% chance). There is a slightly increased risk of a bleed under your baby’s scalp (3-6 in 1000) and a very small risk of a bleed in to their brain (5-15 in 10,000)
Forceps are larger and metal compared to a simple cup, so can look a little scary and a little medieval and it’s often for this reason that some people feel that they would refuse this type of delivery. Forceps are like big spoons, with a large hole where the ‘cup’ of the spoon should be. The circular part of each forcep is guided in to the vagina to cradle the baby’s head, the long handles will be crossed over each other, to create a stable lock and prevent squeezing together during delivery. Again with each contraction, you would push and your baby’s head would be guided down and out. Your baby may have a small mark around their cheek or forehead, but this should be fairly minimal. The risks are slightly less to your baby in terms of a bleed, but you have an increased chance of a significant tear involving the muscles of your back passage (around 8-12% compared with 1-4% with a ventouse)
Will I be given pain relief?
If you end up needing this kind of delivery, it would happen in hospital, either in a labour ward room or in the operating theatre. If you are in theatres it would normally be because we anticipate the delivery may be a little more tricky and therefore the anaesthetist would normally pop an injection in your back (similar to an epidural), in case we needed to do a caesarean in an emergency. If you were in a labour ward room, you would be given an injection of local anaesthetic, to help reduce any discomfort. There will be a few more people around than normal, which can be distracting, 1 or 2 obstetricians, normally two midwives and a paediatrician.
What are the reasons for an instrumental delivery?
1. Your second stage is prolonged
We consider the second stage of labour starting from when your cervix becomes fully open (10cm), with the active phase starting once you are pushing. As obstetricians, we would normally consider 1-3 hours normal for the whole of the second stage. It’s very dependent on what baby number this is and whether you have an epidural.
The following can reduce your chance of needing an instrumental delivery:
- Continuous support in labour
- An upright or side lying position
- Avoiding epidural
An epidural can increase the chance of you needing a hand, for a couple of reasons:
- It’s harder to feel the urge to push.
- You’re able to be less mobile and often are lying flat.
For this reason, we normally recommend that women with an epidural have a little bit more time to let gravity and contractions move your baby a bit further before pushing. It’s also worth noting that with modern ‘mobile epidurals’, you can often move around a little more easily, which helps reduce this risk.
There are various reasons a labour may not be progressing other than an epidural. It may be that you become exhausted after a long labour with no energy left to push, sometimes contractions slow down or may not be strong enough or it can be the position or size of your baby that may slow things down. It’s worth mentioning that you are also statistically more likely to require an instrumental delivery if you are significantly overweight.
Why does this matter?
When the third stage becomes prolonged, babies can be more unwell when they are born. We know that after 3 hours, the Apgar score (a predictive measure of wellbeing at birth) drops, so we would normally step in to give a hand at this point. Birth can be just as exhausting for your baby as you and we want to prevent things from reaching the stage where there’s a concern about your baby’s wellbeing.
2. Concerns about your baby
The other main reason would be if your baby is showing signs that it’s struggling when we monitor it’s heart beat, or if we see bleeding or meconium (your baby’s first poo). This is understandably quite scary for you and your partner. Occasionally it will be a sudden thing where an emergency buzzer is pulled and lots of people arrive. Other times your doctor may come in a few times during your labour, discussing that some assistance may be needed soon.
Either way, make sure you ask questions if you feel that events are escalating and you don’t understand what’s happening. Events do tend to happen quite quickly, but it is your body and regardless of an emergency, your consent should always be expressly given.
Refusing an instrumental delivery
If your baby is low enough in the vagina, we normally would recommend an instrumental delivery over a caesarean, as it’s often the quickest way to deliver your baby and avoids major surgery. The doctor helping your delivery will make a decision about which instrument to use based on their assessment and unfortunately is not something you can choose as it’s a clinical decision based on your baby’s position and how much the head moves with each contraction. Therefore if you are clear you do not want an instrumental delivery or perhaps would refuse a forceps delivery, it’s important to make this clear early on, as this is not the conversation you want to be having in the heat of the moment as opting for a caesarean section when the baby’s head is already very low in the birth canal can be more dangerous for both you and your baby.
Does this involve a cut?
With an instrumental delivery, especially if it’s your first baby, most doctors would give an episiotomy (a cut to the side of your vagina to create a little more space). The purpose is to reduce the risk of tearing and causing a more significant injury. Perineal massage in the antenatal period may reduce the chance of needing an episiotomy. If you do have a cut, it will be repaired immediately afterwards with dissolvable stiches. Making sure you have good pain relief, stay well hydrated and keep the wound clean afterwards should be part of the postnatal advice, so please ask if you are unsure.
As part of our online antenatal course we talk about all of the above in more detail and aim to prepare you for all eventualities. We also include hypnobirthing, which can be hugely beneficial tool to help calm you when things feel a little out of control. There may be things you had planned for that feel like they go out the window in an emergency situation. Perhaps you want to have delayed cord clamping, or your partner cutting the cord and if everything’s okay with your baby this can often still be facilitated. As soon as it’s safe to do so your baby should be brought directly to you, it’s okay to ask for your baby to have skin to skin with you or your partner. Hopefully by having this knowledge you will feel more empowered to speak up if you end up having this kind of birth.
Dr Leah Deutsch is a senior registrar working in obstetrics and gynaecology in a busy North London Hospital in the NHS and a member of the Royal College of Obstetricians and Gynaecologists. She is also a yoga teacher, specialising in pregnancy yoga and believes in a holistic approach to care. This information is not intended to replace that of your health care provider and is simply meant as an adjunct to help empower your experience.
Royal College of Obstetricians and Gynaecologists, Green Top Guideline No 26 ‘Assisted Vaginal Birth’
Royal College of Obstetricians and Gynaecologists Consent advice No 11