Sydney Pelvic Floor Health

Forceps

Forceps belongs to the past, not the future 

Cesarean Section rates have become a political issue, attracting the attention of governments, health bureaucrats and professional organisations. In some instances this has led to a renewed interest in Forceps delivery, even Kielland’s rotational Forceps, because it is true that Forceps can deliver babies that could not be delivered vaginally with a Vacuum. Forceps provides a ‘mechanical advantage- it allows harder and faster pulls, as we all know. But of course harder pulls do more damage. Patients deserve to know. There is no area in Medicine where doctors are allowed to keep quiet about complications so as to not ‘frighten’ the patient. Doctors and midwives are legally required to provide accurate and up to date information on anything we do in Labour Ward- and this often simply doesn’t happen. This is especially true for Forceps, the one intervention most likely to cause serious damage and long-term disability to the mother. In the past, ignorance was an excuse since doctors really didn’t know that much about obstetric trauma. Over the last ten years however we have learnt a lot, and not informing patients properly about the downsides of Forceps is not just unethical but may well be medico-legally dangerous. 

But then Forceps rates have been increasing in the UK since 2005, and more recently in Australia. At one top Sydney Hospital, the Forceps rate has quadrupled since 2002. And obstetricians know why that is happening. To push Forceps in an attempt to reduce C/S rates is a seriously bad idea which is based on ignorance of the recent medical literature. Forceps is associated with a much higher likelihood of major damage to mothers, especially to the anal sphincter and pelvic floor (levator ani) muscle, which can result in major future health problems such as pelvic organ prolapse, urinary and fecal incontinence and sexual problems. Hence, its use should be avoided whenever possible. This is particularly obvious for rotational Forceps. 


Background 

Cesarean Section (C/S) rates have been rising across the Western world as well as in developing countries. In the US, C/S has become the commonest surgical procedure. In the United Kingdom and Australia, policymakers have been very active in trying to rein in this shift in practice, partly due to the cost of cesarean delivery. The results of such activity are guidelines, e.g. those issued by the National Institute of Health and Clinical Excellence in the United Kingdom (NICE) and policy directives such as ‘Towards normal Birth’ in New South Wales, Australia. Sometimes, the involvement of obstetricians in the production of such documents has been minimal. Increasingly, C/S rates are used as the key performance indicator of obstetric services, a trend that may have negative consequences, such as higher blood loss after childbirth rates due to a tolerance of longer labours, higher likelihood of baby deaths due to a greater emphasis on vaginal birth after Caesarean, and of course more maternal trauma due to Forceps. The American Congress of Obstetricians and Gynecologists and the Society for Materno- Fetal Medicine have recently published documents that promote Forceps as a means of reducing C/S rates, and the Clinical Excellence Commission in NSW, Australia, has published a document that very likely will result in the conversion of easy Vacuum deliveries to primary Forceps in order to help with the training of junior doctors. 


Historical aspects 

The last 50 years have seen a progressive reduction in Forceps rates in many countries and regions, starting in Scandinavia, where Tage Malmstroem invented the modern vacuum extractor, and in Germany, where the instrument became popular in the 60s. Progress in the Anglo-Saxon world was slower, but in 1989 a prominent UK obstetrician and his famous epidemiologist son stated “The obstetric vacuum extractor is the instrument of choice for operative vaginal delivery” and, after summarizing what little was known then on maternal birth trauma, “The only justification for accepting preventable maternal morbidity on this scale would be good evidence that forceps as the instrument of first choice had some compensating advantages for either women or their babies.” 

By the 1990s, Vacuum was increasingly used in the United States and in the UK, where more than 50% of vaginal operative deliveries were Vacuums by 2000. It seems that this trend is now being reversed. In the UK, Forceps rates have more than doubled in the last ten years, from 3.3 to 6.8%. In fact, colleagues are increasingly doing rotational Forceps, an instrument that was considered way too dangerous to use when I was a student in Heidelberg in 1982-88. 

This come-back of a highly traumatic procedure arises from a focus on the wrong outcome measure or performance indicator- i.e., C/S rates. Surely the ‘key performance indicator’ of obstetric services has to be maternal and neonatal health problems and deaths, not the numbers of any one particular procedure. And if anyone (journalist, administrator, midwife or community activist) thinks we should do fewer Caesareans then we should remind them that such change in practice must only happen once a few decent trials have shown that such change would be a good idea. 

And then there is the patients’ point of view, which should be central to all we do. Doctors are required to obtain informed consent prior to surgical intervention. That actually doesn't happen very often in busy public O/G departments. I doubt whether many women, when provided with all available information, would choose a rotational Forceps over an emergency Cesarean Section, or Forceps over Vacuum. Due to the fast pace of progress in this field, many colleagues don't yet know how much (and what kind of) information they will soon need to share with their patients. This is probably part of the reason why Forceps rates vary so much even within states. In Australia, there are reports of Forceps rates of over 15% in University hospitals, while at my own institution it is about 2%. 

The consequence of this variation is that in one hospital, less than 10% of first- time mums may suffer a major pelvic floor tear or 'avulsion', while it may be 25% in another Labour Ward, only a few kms away. In lay terms, the pelvic floor muscle is torn off the pubic bone. It seems clear that Vacuum is much less likely to cause such damage than Forceps, based on nine studies in six countries comprising over 2000 patients seen between 2 months and 10 years after their first birth. 

Levator avulsion reduces pelvic floor function and results in a markedly increased risk of prolapse, especially cystocele and uterine prolapse, which may be difficult to treat by conventional means. The more evidence regarding such trauma appears in the world literature, the more difficult it will be to defend obstetric practice that results in such permanent damage- unless the patient was fully informed of this risk and consented to the intervention that caused the trauma. I suspect that, of the next 100 women having a forceps in Australia (or anywhere else), only a few will be informed of this risk. One can only be grateful for the fact that, for the time being, most of them will not be rotational. 

HP Dietz, Sydney