Tuesday, October 14, 2008

Instrumental delivery is avoided with elective cesarean delivery

The unpredictability of a planned vaginal delivery is one of the reasons that some women prefer to arrange a planned cesarean delivery for the birth of their child. The overwhelming majority of planned cesarean deliveries result in the very same outcome, while unfortunately, planning a spontaneous vaginal delivery does not guarantee a spontaneous vaginal delivery outcome.

What's the likelihood of needing forceps, ventouse or both?
In 2006-07, the NHS in England estimates that only 52% of deliveries were 'normal deliveries' (the NHS' term, not mine), defined as those 'without surgical intervention, use of instruments, induction, epidural, spinal or general anaesthetic'. Table 12 states that, "For all deliveries with a spontaneous onset of labour just over three quarters resulted in a spontaneous delivery; approximately 12% resulted in an instrumental delivery; and nearly 12% resulted in a caesarean."
This means that 1 in 4 women planning a vaginal delivery will end up needing instrumental assistance (i.e. forceps, ventouse or both) and/or an emergency cesarean delivery.

By comparison, Table 12 reveals that where a cesarean delivery was planned (see: method of onset of labour), 0.9% ended up as a vaginal delivery outcome and 99% had the outcome of cesarean delivery. Unfortunately, the table does not detail how many of these cesarean outcomes were emergency surgeries, but other studies have shown that number to be very small.
This means that 1 in 10 women planning a cesarean delivery will have an unplanned vaginal delivery outcome, and only 0.1% will need instrumental vaginal assistance.

How is this a 'benefit' with planned cesarean delivery?
The NHS Maternity Statistics summary puts the total number of instrumental deliveries at 11.5%, but again (see blog on episiotomy occurrence below), you need to look at the data a little more closely to find out what percentage of vaginal deliveries involved this type of assistance. Table 12 shows that while 12.4% of vaginal deliveries that began spontaneously required instrumental assistance, the occurrence rate rises to 14%, 16% and 17.1% for vaginal deliveries that were induced. Compare these figures with the 0.1% occurrence with a planned cesarean delivery.

Then look at the medical research on the repercussions of instrumental delivery: increased risk for pevic floor disorders, incontinence, perineal pain and other long-term health issues (see my website for listings of medical studies). Remember, it is not my aim to put women off having a vaginal delivery or in any way to criticize women who choose this birth method - but the avoidance of an instrumental delivery and its associated risks serves as another legitimate reason why some women decide to schedule a cesarean.


Christine Fiscer, Birthkeeper said...

Instrumental delivery can also be avoided by avoiding intervention, and epidurals, in labor.

It's a simple fix. Really.

And are you unaware, or simply ignoring, that a good number of cesarean babies are pulled out quite roughly with a vacuum extraction?

So are we worrying about babies here, or mom?

So much can be changed by changing the way that women view birth. The less afraid we are of it, and the more educated women are to what interventions do and cause in labor, the more problems like this are avoided.

cesarean debate said...

birthkeeper - If you read the research on this, you'll know that instrumental delivery can also occur where no epidural has been administered.

As far as I am aware, the vacuum extraction you refer to occurs during emergency or medically necessary cesarean deliveries - not the more straightforward delivery in a healthy maternal request planned cesarean delivery. But please, I would be happy to read any specific research papers that you can show me that suggest otherwise.

You propose that through a reduction of birth fear, combined with a thorough preparation for vaginal delivery, a woman will automatically avoid instrumental delivery.

This is simply not true, and I think it is typical of the mis-information that is given to women about the risks and benefits of vaginal delivery. You need to be honest with women about what might happen, and not simply lull them into a false sense of security that with the right attitude, nothing can go wrong.

Christine Fiscer, Birthkeeper said...

Ah, did I use blanket statements? I don't see that I did.

I said that the use of instrumental delivery can be DECREASED, and avoided, if more women avoid epidurals, and inductions.

The *fact* is that epidurals are present in most of the vaginal births that occur within the hospital walls. And the *fact* is that epidurals increase the risk of instrumental delivery dramatically. By more than 50% in most studies.

When compared to out of hospital birth statistics, the rate of episiotomy and instrumental delivery is STAGGERING in the hospital. You don't find that interesting? Midwives often have an instrumental delivery rate of less than 5%. In the hospital, instrumental delivery is quite commonplace, and again, especially when an epidural is chosen by the laboring woman.

Yes, women need to be informed of what may happen...I wholeheartedly agree. This is why I make it a personal goal to make women aware of the differences between a hospital delivery, and a home or birth center delivery. Much better outcomes, much higher satisfaction, and much healthier women and babies. ;)

cesarean debate said...

birthkeeper - Even if you use the word 'decreased', this still means that my blog post title remains correct - episiotomy is avoided with planned cesarean delivery.

Even if you insist on saying that giving birth at home will secure the same avoidance of an episiotomy, that does not alter the fact that I choose to give birth via planned cesarean delivery in a hospital environment.

That is where I feel most comfortable, and I don't know why this upsets you so much. If you want to give birth at home, that is for you to decide.

Christine Fiscer, Birthkeeper said...

Whatever decision is made by you, or by me is not the issue.

It is the misrepresentation of data, and inaccurate conclusions that you make that I have a problem with.

By comparing the avoidance of episiotomy to a planned cesarean delivery, you are very misleading to women who choose not to do research for themselves. And unfortunately, we have a whole lot of those running around.

I'm sorry that you feel most comfortable in an environment that continues to abuse women, create traumatic situations, and harms babies.

I pose a challenge to you. Do some thorough research on home birth. Thorough, unbiased research. Go read the studies. Compare the outcomes of PLANNED home birth, planned hospital vaginal birth, and planned cesarean.

Can you bring yourself to do it?

Again, this has nothing to do with personal preference, and everything to do with the misinformation that you are representing...or the incomplete information that you are representing without offering the third, and very viable, option.

cesarean debate said...

birthkeeper - You are correct that it is not all about me or you, and this is why I list medical research papers on the risks and benefits of planned cesarean delivery on my website.

I encourage women to educate themselves further, but if they want to find out more about home births, my website and blog are not the best places for them to do that. I am interested in hospital birth data because that is where the majority of births occur and that is where the vast majority of medical research takes place.

Home birth is taken up as an option by so few women that I simply do not have the resources to go into that area of research as well - I suggest you go to Dr Amy Tuteur's blog (homebirthdebate.blogspot.com) to continue your debate on this subject.