Severe injuries from forceps, vacuum during childbirth called 'unacceptably high' in Canada

Canadian mothers face high rates of severe, long-term injuries during childbirth through the use of forceps or vacuum delivery that urgently need to be reduced, the authors of a new analysis say.

Operative vaginal delivery (OVD) refers to using forceps or vacuum in the second stage of labour when the cervix is fully dilated. Health-care professionals may need to use the instruments if labour stalls or if the fetus is at risk.

In this week's issue of BMJ, epidemiologist Giulia Muraca, an assistant professor in obstetrics and gynecology at McMaster University and her co-authors, note that since 2010, Canada has had the highest rates of maternal trauma during forceps and vacuum deliveries, 16 per cent, compared with the average of other high-income countries, about 5 per cent.

"These rates of injuries are absurdly, unacceptably high," Muraca said in an interview. "And there's been … no concerted effort to reduce them. Perhaps even worse, we're not even recognizing or talking about them."

Up to 15 per cent of deliveries in Canada include use of forceps or vacuum.

Muraca and her team from the University of British Columbia, a patient and researchers in Sweden said of the more than 35, 000 single infants born after attempted operative vaginal delivery in Canada, one in four attempted forceps deliveries and one in eight attempted vacuum deliveries result in obstetric trauma. Most commonly obstetric anal sphincter injury occurs.

When Laura Ralph in Vancouver gave birth to her son seven years ago, she recalls it was a chaotic and anxiety-provoking experience.

"At one point, I was worried that my son might die and that I might die," Ralph said through tears.

Ralph needed a blood transfusion in the operating room and has pelvic prolapse, where the pelvic floor muscles weaken. In her case, the bladder fell into the vaginal wall.

Pelvic physiotherapy is a common treatment for the urinary incontinence that can result.

After more severe tears, pelvic pain, sexual dysfunction and fecal and anal incontinence "can have devastating effects on social, psychological, and physical wellbeing," the reviewers wrote.

Empower early in pregnancy

Ralph said she wanted to contribute to the paper to try to prevent others from experiencing injuries and fallout she did, like not being able to exercise as she'd like. Ralph participates in pelvic prolapse groups on Facebook. She later had twins born through planned C-sections.

Muraca suggests taking a page from the play books in Australia and the United Kingdom, where lowering rates of injuries are a national priority.

Dr. Modupe Tunde-Byass, an obstetrician and gynecologist focused on high-risk births at North York General Hospital, said using forceps and vacuum are decisions providers make on a case-by-case basis.

Tunde-Byass said in trained hands, forceps and vacuum are still safe options. But women should be empowered early in their pregnancy to learn about alternatives, including C-sections and episiotomy.

Episiotomy and other options

"We don't want the pendulum to swing so far away such that women are robbed of the opportunity to have a natural birth vaginaly," Tunde-Byass said.

Muraca attributes Canada's high rates of maternal injuries in part to reduce the similarly high rates of C-sections in this country, following a landmark clinical trial.

"One other thing to consider would be episiotomy," Tunde-Byass said. "It's being demonized and a lot of providers do not want to do episiotomy because it's part of the quality improvement dashboard."

Both Tunde-Byass and Muraca said when providers correctly perform episiotomy — a surgical cut made during childbirth, to aid a difficult delivery and prevent tears — then many of the injuries are prevented. That's what studies and moves in Australia and the U.K. show for episiotomy performed at least 60 degrees away from the rectum so it does not extend into the sphincters.

Birthing position, such as pushing while lying on the side, also matters Tunde-Byass said.

Dr. Amanda Black, president of the Society of Obstetricians and Gynecologists of Canada, said the researchers' country comparisons may not be fully apples to apples. "Having said that, I don't think we can discount the fact that there is some concern about the fact that our rates of obstetric sphincter injury may be higher than compared to our colleagues."