Forceps... The truth about the salad tongs
So I had promised a blog post about forceps maybe 2 months ago and then I got stupidly busy and I didn’t get round to it….. I read a post recently about how forceps should be considered a good thing. I mean, the message was a bit jumbled but ultimately the truth is sometimes your baby needs coaxed out for theirs and your safety. Lets clear something up.. forceps are safe when used correctly.
Like anything, you will find stories on the internet, things that have been written despite limited facts being available. It is no different to any other profession in that the right tools in the wrong hands then become the wrong tools.
It is another medical practice that is demonised. Another tool for women to judge other women. Something that can make people feel like they have failed. All of the above being complete and utter crap.
No one wants giant, scary looking, silver salad tongs up their lady bits, (and frankly we don't want that for you either) but the sometimes the alternatives are a much scarier prospect. Forceps have a time and a place and I have seen some amazingly gentle forceps deliveries with excellent Doctors (especially here) that have resulted in healthy mum, healthy baby and a positive experience.
There are many reasons you may need forceps to help you birth your baby:
Your baby’s head is not in a good position for moving down through the birth canal
Your baby is facing a certain way and this can present a less than optimal head diameter so may need help turning
Your baby is in distress and birth needs to be expedited
You are unable to, or have been advised not to, push during birth
The purpose of an assisted vaginal birth is to mimic a normal (spontaneous) birth with minimum risk to you and your baby. To do this, an obstetrician uses forceps to help your baby to be born.
Now I know it doesn’t sound like that beautiful birth you imagined in your head but if we need your baby out because that is how we achieve the best outcome then trust me when I say this is for the best. And I want you to think about this, if forceps can deliver your baby safely in such circumstances and save a caesarean section then isn’t that also worth considering.
I don’t care about the method by which your baby comes out as long as you're safe and happy. All I care about is that you are aware of why certain things are suggested to you. What the reasoning is and what the risks are. Your choice. Your body. Your baby. Knowing these things can ensure that even with a change of plan you can still have a positive experience.
So here is something which comes as no surprise to any of us…. Methods of reducing your chances of needing a forceps delivery:
SUPPORT - Women who have continuous support during labour are less likely to need an assisted vaginal birth, particularly if the support comes from someone you know as well as a Midwife. No surprise there. If you feel safe and supported then your body will do what it is meant to without fear, anxiety or distractions.
So pick your birth companions well. Don’t let the MIL in just because she thinks she should be there… If people come to visit when you are in labour then tell them to buggar off until baby is out. Pick people who make you feel safe and who know you well enough to know your non verbal cues. This is a time to BE SELFISH!
ACTIVE LABOUR – Stay upright. Move. Use a ball. Squat. Dance. Do it all. Being upright as much as possible encourages descent of baby in to the pelvis in the optimum position.
If you have had an epidural then fear not. There are ways to recreate the open pelvis positions. Lying on your side, using a peanut ball between your legs, sat up and forward on the bed leaning over a birthing ball.
TAKE YOUR TIME - If this is your first baby and you have an epidural, the need for a forceps birth can be reduced by waiting until you have a strong urge to push or by delaying when you start pushing. When your cervix is fully dilated (10cm) you should be advised on having at least one hour “Passive’’ stage. This is assuming your baby is perfectly happy at this point. The passive stage allows your baby to utilize the contractions (that you shouldn’t feel) and move down slowly of their own accord. The lower they move then the less distance you have to push them. There is no point pushing if you are fully dilated but the baby is up in your guts…. That is just setting you up for failure. So make sure you mention the PASSIVE STAGE to your OBGYN or Midwife (Although I would hope most will accommodate this).
So what actually are forceps?
Well they are smooth metal instruments that look like large spoons or salad tongs. They are curved to fit around your baby’s head.
There are generally 2 types that we talk of as Midwives and you will hear the terms thrown around:
Lift Out: This is when baby’s head is nice and low and you need some small assistance (for whatever reason) to guide the head out.
Trial of Forceps: More commonly known just as a “trial”. This is when we perhaps need to help turn your baby’s head in to a more favourable position before we try and guide them down the birth canal. This should ALWAYS be done in a theatre. You will need a spinal/epidural top up and it requires different forceps. It isn’t necessarily more dramatic. We just like to be in the best place for you both.
It is really important to mention this here… Forceps DO NOT work unless YOU DO! We don’t just pop some salad tongs up there on your baby’s head and yank them out. We need you to push as if they were not even there. The same amount of effort is required from you when using as when not! So all this failure talk is very irrelevant is it not?
As always, I think knowing about something takes a lot of the fear away. Understanding it means that should you require this option, you are armed and ready to accommodate these changes and still have the positive birth you desire.
So it pretty much works like this:
Your obstetrician or midwife will examine your tummy and perform an internal examination to confirm that a forceps delivery is appropriate for you. Your bladder will be emptied by passing a small tube (catheter) into it. This is necessary, it reduces the chance of any damage to the bladder and also if you have a very full bladder it can stop your baby’s head coming down the birth canal.
Pain relief for the delivery may be either a local anaesthetic injection inside the vagina (pudendal block) or a regional anaesthetic injection given into the space around the nerves in your back (an epidural or a spinal).
You may need to have a cut (episiotomy) to enlarge the vaginal opening and allow the baby to be born, although this is not always the case, particularly if you’ve had a baby before. If you do not have an epidural, the entrance to the vagina will be numbed with local anaesthetic. Believe me when I say it is advisable to trust your midwife/doctor when they tell you that it is indicated. This is because with an episiotomy we are giving ourselves more room to accommodate the forceps with the view of minimizing any potential damage. Not doing so could result in serious perineal trauma.
The forceps are carefully positioned around your baby’s head when you are not having a contraction. They lock together and form one handle. If they do not lock they should not be used.
The obstetrician will wait until you are having a contraction (if you have an epidural then your midwife will tell you when one is happening) and then ask you to push while he/she gently pulls to help deliver your baby. It can look brutal, your Doctor will look like they are having a workout by putting their back in to it, this is normal, do not panic.
It can take more than one pull. Especially if it is your first baby or the doctor is first rotating your baby’s head before delivering it. If your baby does not deliver after 3 pulls on the forceps ad if a consultant is not present they should be called before any further action is taken. If the decision to have a caesarean section has happened this would usually go ahead at this point. Very experienced consultants may try a fourth time. However this should be done with caution. If a baby will not come after 4 attempts with forceps there is generally a reason.
Forceps are only used to guide delivery of the head, once crowning they are removed and its still all you. You push your baby out.
If baby is happy and screeching then ensure delayed cord clamping and skin to skin. There is no reason – no matter whether you have a forceps in the room or in the theatre – that you cannot fulfill the requirements on your birth plan.
** UAE advice – If your Doctor proceeds to try numerous pulls on the forceps (and for some reason your midwife has become a mute) please please tell them to stop. I don’t want to scare people with this. I want to protect you from anything that may cause you to have a negative outcome or experience. Private healthcare is a business and you are the client – remind them of this.**
Will I be asked for consent?
I really bloody hope so! Do not let anyone put salad tongs up your lady bits without asking you. If they do…. Kick them. Hard. In the face. If your midwife hasn’t already done so.
Forceps will only be used to deliver your baby if they are the safest method of delivery for you and your baby. The reasons for having an forceps birth, the choice of instrument and the procedure should be explained to you by your obstetrician or midwife.
The risks to you and your baby of an assisted birth will be discussed with you. Your verbal consent will be obtained before delivering your baby. If your delivery is carried out in the operating theatre, your written consent will be obtained.
Some of the risks for baby may be:
Bruising, bumps or marks on the sides of your baby’s face – these usually subside nice and quickly
Cone shaped or swollen head
Nerve damage to the face caused by excess pressure (usually only associated with practioners who are not skilled or confident in forcep deliveries)
Cuts to the skin can occur
Bleeding on the brain (rare but possible)
Minor external eye injury
Risks for mum may be:
Significant damage to the perineum (the area between your vagina and your bum)
Increased recovery time after birth
Tears, bruising and injury occurring to the labia and vagina
Risks associated with episiotomy, a severe tear or both
Incontinence problems such as being unable to control your bladder or bowel movements
Painful sex following birth
As with everything the risks seem scary don’t they? But you need to know them. I also encourage you to ask "what will be the risks of NOT doing the forceps?" and listen to that as well when making your decision. It is often the safest method available and avoids massive abdominal surgery. When babies tell us they want out.... they generally mean "I am so over this labour and pushing stuff. I am tired. I'd like out right now please."
It is only ever done when the needs of mum and baby are greater than the risks of the forceps delivery. The complications are real yes, but also rare. But if you understand why we do this, what the risks of using them vs not, then you can still work that in to your birth experience without the negativity.
What happens after your baby is born?
A doctor or nurse who specialises in the care of newborn babies may be there when you have your baby, particularly if there have been concerns about his or her wellbeing or if your delivery is carried out in an operating theatre. Always make sure your wishes for your newborn are heard and make sure that once a quick confirmation of wellbeing has been done that you insist on skin to skin!
Your baby will most likely have some bruising or some forceps marks. Midwife tip: Put a hat on them to cover the marks…. They will fade 😊
So there you have it. A full rundown on the use of forceps. The good, the not so good but the truth. As much as we wish they were not needed, they do have a place in maternity care and I have seen them used by some wonderful Doctors. Get yourself a wonderful midwife as well and you will be in good hands. Ask your Doctor if they are happy using forceps (for UAE women especially - the NHS generally churn out Doctors who use them more frequently).
Whilst I fully advocate working towards a low risk, vaginal delivery I also realise this is not the case for some women. so use what you have read. Even if your birth goes slightly off plan (as many invariably tend to) you can still know what is happening and have a positive experience.
You will probably never look at salad tongs in the same way again though......