Intervention: What thought disturbs you more.

[Inertia]

Hoobley - I was thinking in respect to episiotomy. My perinium has never failed me before, so I have enough faith that it can get through it just fine - but accepting a method that would voluntarily ask for manual perineal dissemination is a whole new ball game.

Oh, and Thank you for the information on examinations. That one is definitely going into the birth preferences. I'm happy enough for them to stand and watch from a distance!

[Yael]

The part of me that is rational would like to know what the sudden need for immediate deliver actually IS, because i seriously can't think of one. Sudden foetal distress - why? I wouldn't let them augment me, or have an epidural, or other drugs, so why is the baby distressed suddenly? In unaugmented natural labours one usually can tell something which might later cause distress (usually poor foetal positioning) is afoot because the labour is slow and doesn't progress much - babies drive labour in normal circumstances and will not do so to the point that they are struggling.

Bec, with DD she went into distress 1 push before she was born, and i was lucky i was that close that i didn't end up with any intervention TBH. Labour progressed beautifully, everything was perfect. Waters were broken at 9cm (but even if i hadn't agreed to that, realistically they would have broken very soon after), third stage began 10 mins later (2 contractions, but there weren't monitoring her, so not sure what HR was doing in that time). My DD had an extremely long cord (infact, the longest they had seen in a very long time), which was wrapped incredibly tightly around her neck, twice. They couldn't get it off her neck, and said to me that i needed to get her out that push. (i also felt them using the doppler i think??) Luckily i mis-heard them, and thought they were telling me "common, you can get her out this push", because i didn't freak out (well, any more than normal), and she was ok. She pooed all over me straight away, and was born very gray and looked like she was dead.

I was lucky she had the waters cushioning her, because i believe i would have (and probably rightly), ended up with a c/s for feotal distress. And if i didn't get her out that push they would have done an episiotomy and whatever else they needed to, to get her out quickly.

So, it can happen right at the very very end, with no warning signs before hand.

To the OP, i had a vacuum with DS, and no episiotomy. I would go with vacuum, forceps and then a c/s. I think that would be the order of a more difficult recovery. In terms of them not being as skilled any more, that is true, but you would be hard pressed to find any single doctor who will do a mid or high forceps anymore (and if you ask anyone but an older nurse, they don't even know what it is anymore, because they will never have seen one). They are hard to learn apparently (my mum is a mid and she told me about them), and you can stuff it up big time learning, so now the risk isn't considered worth it and they will c/s those patients instead. But perhaps the loss of skills in the obstetrics field in favour of c/sing women to avoid litigation is a discussion for a different time?

I would think you are no more likely to have a stuffed up epi than a stuffed up c/s, and the would both suck. I would take a vacuum or forceps over a c/s, because like Kelly said, the impact on future births is huge.

[Inertia]

To the OP, i had a vacuum with DS, and no episiotomy. I would go with vacuum, forceps and then a c/s. I think that would be the order of a more difficult recovery. In terms of them not being as skilled any more, that is true, but you would be hard pressed to find any single doctor who will do a mid or high forceps anymore (and if you ask anyone but an older nurse, they don't even know what it is anymore, because they will never have seen one). They are hard to learn apparently (my mum is a mid and she told me about them), and you can stuff it up big time learning, so now the risk isn't considered worth it and they will c/s those patients instead. But perhaps the loss of skills in the obstetrics field in favour of c/sing women to avoid litigation is a discussion for a different time?

I would think you are no more likely to have a stuffed up epi than a stuffed up c/s, and the would both suck. I would take a vacuum or forceps over a c/s, because like Kelly said, the impact on future births is huge.

I would think the vac without epi is probably now looking more favourable. I know my older sister had a forceps assisted with her first but she wont talk about it - and she is an extremely open person so I can only imagine that it is a trauma she does not want to revisit. An epi is performed around some seriously important muscles and I have put a lot of effort to keep my pelvic floor in good shape after grand multiparity. I still have MWs marvel at the fact that I have avoided ever experiencing incontinence, and its a freedom I want to keep with soon to be 6 kids to look after. Not to mention the other muscles which I really dislike the idea of putting that close to a surgeons blade with me freaking out on the table.

Its funny, but of the whole birth preferences, I never imagined that the bit that I probably wouldn't need would be the hardest part to write.

[~mamaspice~]

Coming from someone who has not yet had a vaginal delivery, I think I would choose:

vacuum, then forceps, then cs.

If I was THAT close to birthing my bub and avoiding major abdominal surgery I would definately want to avoid the cs unless it was really necessary.

I don't know why, but to me, the vacuum seems less traumatic for baby as opposed to forceps. Oh, and a point that I think Hoobley mentioned - they use forceps a lot with caesareans too to get the head out of the incision. My poor bubba girl was yanked out with forceps (caesarean) and had a big mark on her cheek from them to prove it.

[fionas]

Before having DD I might have put it in this order - vacuum, c-section, forceps.

DD ended up being a forceps delivery - no episiotomy and a tiny tear. So now I'm a bit more blase about the forceps BUT I'd had an epidural so couldn't feel TOO much. I might be telling a different story if I hadn't had an epidural but without the epidural I might not have needed forceps. Chicken and the egg.

But actually, I trusted my ob. I know he avoids c-sections at all costs and would only send me for one if that was the best option. The midwives there told me that a lot of obs won't use forceps now and would have simply sent me for a c-section.

[~Saram~]

OK this opinion is coming from someone who had neither but was threatened with them as bub was stuck. Luckily I had the most beautiful midwife who supported my wishes who systematically gave me new positions to try which got bub unstuck and out. The Dr did do an (unnecessary) epi in preparation, without any anestetic (was surprised I could feel it - MEN!) but I think my first choice if bub is stuck or in distress is to move to a different position and see if it helps and buys you more time to think about options.

Having said that I would go with vac, forceps, c-sec but talk to your OB and see what they are more comfortable using and what they would recommend in each circumstance

[Tobily]

I would never choose a caesar over a vaginal birth even if there were instruments involved.

Instrument births don't always involve an episiotomy, although your risk of having one is certainly higher where instruments are used.

The midwives there told me that a lot of obs won't use forceps now and would have simply sent me for a c-section.

This is true I reckon. I have only seen one forceps birth which was in a public hospital, and it would have been a ceasar if she'd been with the private OB that she ditched a week beforehand. Forceps are most often used when the baby is still high - high enough to do a caesarean. The use of forceps is on the decline with obstetricians because they are opting for c/sections instead.

Ventouse most often comes out when the baby's head is on view (ie. baby is very low in the birth canal) and there is a desire to get things over with. Sometimes that's from the mother but most often it's from the caregiver. I have seen one situation where the baby's heartbeat was seriously bottoming out and not recovering and the ventouse was probably justified...but most of the time I see it used it's purely impatience.

The point of all that ramble being that it's rare that instrument use is a life and death scenario.

[Janie]

Mmmm, it's interesting re. the whole forceps/c-section thing. I had a four hour second stage, with a malpositioned and posterior baby. Ob let me go on my own (with midwife support, he was just in the background) for almost three hours before he got ansty. Even then he didn't rush into anything. Ventouse was eventually tried a number of times, but my bubba wasn't moving, he was seriously stuck! Eventually forceps were called for, and with them and some almighty pushes DS was born. The middies all said that any other Ob would have had me in theatre, that I was lucky to have him. I never thought before that that was because of anyone's reluctance to use forceps, but maybe that was what they meant. I think time-frame would have had something to do with it too.

Um, yeah, I would definitely prefer a birth without intervention, but I was glad the forceps were around for my DS's birth, and it was far from a traumatic experience, I loved every minute of it!

[Ca Plane Pour Moi]

I had a ventouse without an episiotomy. But then I had another one with because DS was posterior. TBH, the ventouse was quite easy and fairly pain-free for me. Trying to turn DS was NOT easy or pain-free LOL. I'd go for... actually, I'd go for kicking the Obs in the head before letting them anywhere near me, but ventouse would be my option I guess if I didn't have the machine-gun to hand.

As for "don't let them"... that implies you have a choice which cannot be overridden because someone else says so. I very much hope no-one overrides your choice, Inertia, but having the plan is a GOOD thing because at least that has more of a chance of being the first option someone decides to try, telling you about it when it's almost done, if not a few hours later.

[Tobily]

Mmmm, it's interesting re. the whole forceps/c-section thing. I had a four hour second stage, with a malpositioned and posterior baby. Ob let me go on my own (with midwife support, he was just in the background) for almost three hours before he got ansty. Even then he didn't rush into anything. Ventouse was eventually tried a number of times, but my bubba wasn't moving, he was seriously stuck! Eventually forceps were called for, and with them and some almighty pushes DS was born. The middies all said that any other Ob would have had me in theatre, that I was lucky to have him. I never thought before that that was because of anyone's reluctance to use forceps, but maybe that was what they meant. I think time-frame would have had something to do with it too.

Absolutely Janie. A four hour second stage when it's known that the baby is posterior would be completely unheard of in alot of hospitals. Most OB's would tell you that you're not going to birth vaginally at that point and want to do something. Even with an anterior baby usually 1.5 to 2 hours (first baby) is where there will be pressure to intervene.

[paradise lost]

Bec, with DD she went into distress 1 push before she was born, and i was lucky i was that close that i didn't end up with any intervention TBH. Labour progressed beautifully, everything was perfect. Waters were broken at 9cm (but even if i hadn't agreed to that, realistically they would have broken very soon after), third stage began 10 mins later (2 contractions, but there weren't monitoring her, so not sure what HR was doing in that time). My DD had an extremely long cord (infact, the longest they had seen in a very long time), which was wrapped incredibly tightly around her neck, twice. They couldn't get it off her neck, and said to me that i needed to get her out that push. (i also felt them using the doppler i think??) Luckily i mis-heard them, and thought they were telling me "common, you can get her out this push", because i didn't freak out (well, any more than normal), and she was ok. She pooed all over me straight away, and was born very gray and looked like she was dead.

I was lucky she had the waters cushioning her, because i believe i would have (and probably rightly), ended up with a c/s for feotal distress. And if i didn't get her out that push they would have done an episiotomy and whatever else they needed to, to get her out quickly.

But her head was already born right, or how could they see the cord? And if her head was already born then none of the 3 listed interventions would have been of use, see what i mean?

Your waters DID protect her until they were ruptured for you, and probably that is what they are there for (those small number of babies who need the extra protection for labour) and perhaps if they hadn't been broken she would have had no issues whatever - think of the number of women who have a c/s after AROM because baby is in severe distress - clearly birth works better when not messed with for the majority. Many women's waters break as the head descends and rotates through the pelvis just before birth, and it's possible that they are designed to do so (mine broke 15 hours before DD was born, but i'm sure the 5 stretch and sweeps i had had over the previous 10 days contributed and i know better for next time).

I'm not dismissing your experience, i just don't see how intrumental or surgical assistance would have helped at all. The only thing that could have been done differently is not to have the AROM and that's a lessening of intervention, not an increase.

Bx

[Yael]

If the head is out and not the shoulders, and i couldn't have got her out they would have given me an epi. My friend had the same experience, and even with an epi they couldn't get the baby out, and they used the vacuum to help tug her out.

If they were monitoring me after my waters broke, and she was in distress then, then i would have ended up with probably a late c/s.

Yes my waters were broken, and it was also 15 mins before she was born, so although it is technically an intervention, they were probably just about to break anyway. At which point the same thing (i.e. late distress) would have happened anyway. I declined the offer for them to be broken at 6cm (and my obs respected my choice), as i felt that it was an unnecessary intervention, and in the future i would make the same choice with subsequent births, that the waters are there to protect the baby for a reason.

The point of my story is to point out that even without obvious signs of something going wrong, things can change at the last minute, and this does lead to surigcal intervention when necessary. And i would have been happy for them to do an epi if my daughter needed it, becuase i trust my care provider that he would only do these things if necessary.

[OceanPrincess]

... becuase i trust my care provider that he would only do these things if necessary.

Hear hear

[Inertia]

Thanks for all this guys - it certainly is food for thought. I am guessing in the case of Lyta, they would have opted for a c-sec anyway if their planned induction didn't work. Of course it still annoys me that they were outside discussing "what to do with me" without involving me in the discussion at all - while I am actually delivering the baby by myself with my DH thumping the nurse call button, lol. In their opinion I had stalled (from a check they made 4 hours before hand). Another point on why I don't want the continual checks. I most certainly am not going to be rushed! Going through the public system, I wont have a choice of care provider - although my regular doctor is on the antenatal registrar at the hospital I am going to and gave me his after hours number - so they really don't want to push me to use it because my Doc is very much about supporting me - not his bank balance.

I am very much against the epi because the whole idea seems redundant when I am not at risk of tear anyway - so that will be on the plan. I really dislike the foetal monitor so can I opt for a doppler or other form of intermittent monitoring? Obviously if/when my membranes rupture spontaneously then I have no objections to them checking on my baby, but I find the monitor actually centralises contraction pain to an almost unbearable level - and then everything slows down.

I swear, if it were not for all the options my birth preferences would read like "Stand at the door and I will let you know when I am done!"

[Toomanytoomany]

I'd go for... actually, I'd go for kicking the Obs in the head before letting them anywhere near me, but ventouse would be my option I guess if I didn't have the machine-gun to hand.

This made me laugh quite a bit.

[widdly]

I would go straight for the c-section.

For me, I tore and got stitched up and that really traumatised me for quite a while, so rather than have the trauma of forceps or ventouse I would go straight for the c-section and keep my vagina in tact.

[Glamourcide]

I am *petrified* of episiotomy... don't ask me why, I just am. Like, phobic. During DD's birth, the old hag midwife I had (oh, she was a right ol' cow... don't get me started) leaned in close as I was struggling to gather enough strength to push again, and threatened to 'cut me' if I didn't 'stop whingeing and do what you're told'. I was so frightened that she would just go ahead and cut me without my permission that I shut up and just about tore myself to shreds trying to get DD out - there was nothing wrong with her, the monitoring equipment had slipped and they weren't getting a proper reading of her heartbeat so the old cow assumed she was in distress and kept hurrying me.
Thankfully I gave myself enough time to stretch naturally, I didn't tear or have any problems and it has just made me more determined to avoid an epi unless it is literally a matter of life and death.

I would much, much prefer vacuum over anything else, provided it could be done without an epi. Forceps I would take if necessary, again, but I'd still prefer a vacuum extraction over forceps - I watched a few assisted-birth videos before having DD and vacuum looked like a much gentler, less traumatic option than reefing the poor kid out by its head with big tongs...

C-sec would be an absolute last resort for me, but as others have said, a lot more doctors these days don't offer the option of forceps or vacuum and will just send you for a c-sec as they 'know what they're doing' and don't have much experience with forceps etc. In fact, when I was discussing birth options with my midwives before DD's birth, and I mentioned vacuum, I was told flat-out that 'we don't even *have* vacuum equipment in this town - it's forceps or c-sec if you can't do it yourself'.

[Snacks]

I really dislike the foetal monitor so can I opt for a doppler or other form of intermittent monitoring?

Of course. They will probably insist on fetal monitoring only if they have already intervened previously (i.e. synto drip or epidural). With Natty, I was only monitored with a doppler intermittently. (In the pushing stage, they would monitor her briefly between contractions which was still bloody annoying but much better than the fixed monitor!)