Maternal trauma: What to know about risks of forceps and vacuum deliveries in Canada
A Canadian researcher says high rates of injuries have been documented but ignored for years.
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A new data analysis has found Canada has the highest rates of injuries from forceps and vacuum delivery among high-income countries.
These injuries have been "documented for over a decade without efforts to address them," according to a release from McMaster University.
The paper titled "Maternal and neonatal trauma during forceps and vacuum delivery must not be overlooked," published in the BMJ, calls for transparency and action in Canada.
This research came about when obstetrics organizations in North America put forward documentation on efforts to reduce the number of cesarean deliveries in complications during birthing. "The recommendations were instead of having a cesarean delivery in that situation, perhaps we can increase our use of these instruments — forceps and vacuum delivery," lead author Giulia Muraca explained to Yahoo Canada.
At the time, she thought it was a "sensible" recommendation, before beginning to question whether these tools were actually safer that a C-section. Years later, data showed "extremely high rates" of maternal trauma from these instruments, something that hasn't been acknowledged before.
"The moral of the story there was that all of these options have their own sets of risks and benefits — and there's no real winner," Muraca claimed.
But what exactly are the risks, and why are injury rates so high in Canada? Read on for everything you need to know.
What is maternal trauma?
According to Muraca, maternal trauma during childbirth includes severe injuries to the pelvis and pelvic organs, particularly focusing on anal sphincter injuries from severe perineal lacerations (vaginal tears). These occur during instrumental deliveries, such as forceps or vacuum-assisted deliveries.
The consequences of such injuries are anal and fecal incontinence in years following delivery, or in plain language: involuntary pooping.
"It's not something anyone likes to talk about," she claimed, adding the injuries can destroy a person's quality of life.
"People can no longer run anymore, they have sexual dysfunction and their sex lives are decimated, they lose their jobs, they their relationships fall apart, and their sense of self goes out the window."
There's a great deal of of mental illness that stems from having these injuries.Giulia Muraca
Laura Ralph is one patients that suffered a pelvic floor injury during her son's delivery due to the use of forceps. In an email release, Ralph said she wasn't told about the potential risks.
"I remember a cesarean delivery being discussed, but I don't recall whether one was offered to me. I was also completely uninformed of the risks of cesarean versus forceps delivery," Ralph said.
Her delivery has suffered long-term complications. According to the release, "she had to use a pessary – a device inserted into the birth canal to provide support after pelvic prolapse."
Ralph now fears having any more children because of that trauma.
"I often think of that conversation about cesarean delivery and wish someone had taken a few minutes to explain the pros and cons of each potential outcome with me."
What the data shows
Muraca's research found more than 35,000 babies are born each year in Canada with the use of these instruments. Compared with other high-income countries, data from 2019 shows Canada has the highest rate of maternal injuries, at 16.3 per cent — a number Muraca called "alarming."
"One in four people sustain these injuries following forceps deliveries (25.3 per cent) and one in eight with vacuum deliveries (13.2 per cent)," the release read.
While mother bare the brunt of the injuries, about 650 infants in Canada annually (one per cent) also suffer injuries that lead to longterm disability.
Why does Canada have such high rates?
Several factors contribute to Canada's high rates of maternal injuries, according to Muraca. Some of these include:
High rates of forceps usage
Compared to countries like Norway (three per cent), the United States (five per cent) or the Netherlands (zero per cent), Canada uses forceps more frequently — in six per cent of deliveries.
Lack of episiotomy practice
Canada lags behind in the use of mediolateral episiotomies (a controlled incision), which are used more frequently in countries like the United Kingdom and Australia.
Insufficient training
There is less training in instrumental deliveries as they are becoming less common. However, Muraca pointed out "if we're seeing these high rates of trauma happening for 10 years, who do we have to instruct people on how to do this safely? The entire training paradigm needs to be revisited."
Insufficient effort
Unlike countries like the U.K. and Australia, Canada has yet to establish a national strategy for addressing maternal trauma. Acknowledging the problem and dedicating resources to this is "overdue."
We haven't cared about it enough to create a strategy to reduce these injuries.Giulia Muraca
What can be done to improve outcomes of birthing people?
The study's findings should be a wake-up call to healthcare professionals, policymakers and expectant people.
Muraca's recommendations now are recognition, transparency and action.
"We need to recognize that this is an issue that merits and that warrants a concerted effort," she claimed.
She said the risks of instrumental deliveries need to be openly talked about, and expectant people need to be warned. "I don't want to receive any more emails from people saying 'I didn't know, I thought I was the only one — no one ever told me,'" Muraca said. "This needs to be communicated to pregnant people."
When the options are a cesarian or instrumental delivery, pregnant people should be able to make an informed decision on what suits them best.
"There's no real hierarchy of what's safer, and what's less safe. But there are different sets of risks and benefits."
Muraca wants this to be a written protocol — that there must be informed consent before a pregnant person is in labour.
She also wants these findings to trigger a national response to lower the rate of these injuries.
"They do not have to be this high; they are not unavoidable; we can do a much, much better job."
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