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Forceps severely injure 1 in 4 Canadian mothers when used in childbirth: study

In this file photo, a doctor uses a hand-held Doppler probe on a pregnant woman to measure the heartbeat of the fetus on Dec. 17, 2021, in Jackson, Miss. (AP Photo/Rogelio V. Solis, File) In this file photo, a doctor uses a hand-held Doppler probe on a pregnant woman to measure the heartbeat of the fetus on Dec. 17, 2021, in Jackson, Miss. (AP Photo/Rogelio V. Solis, File)
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Mothers and birthing parents in Canada are severely injured in as many as one out of four deliveries involving forceps, according to a study published in the BMJ Thursday.

The study's authors – epidemiologists, obstetricians, urogynecologists and community advocates from Canada and Sweden – found more than 10 years of evidence that forceps and vacuum deliveries in Canada are linked with a high rate of injury in mothers and babies. In fact, among high-income countries, Canada has the highest rate of maternal trauma after births in which tools like forceps and vacuums are used, according to a study published today.

Despite the risk of harm, lead author Giulia Muraca from McMaster University said little-to-no effort has been made to highlight or solve the problem in Canada.

"It's hidden. No one speaks about it because of obvious reasons, like it's embarrassing or some people think this is just a normal side effect of childbirth, and it's not," she told CTVNews.ca in a phone interview on Wednesday.

The study calls for a national shift toward increased recognition, transparency and action to better inform patients of the risks and prevent future injuries.

INJURIES IN ONE OUT OF EVERY FOUR BIRTHS

When labour stalls and pushing is no longer an option, doctors often recommend forceps- and vacuum-assisted deliveries as safe alternatives to a C-section delivery. These deliveries are also known as operative vaginal deliveries.

However, according to data on maternal and neonatal injury and death, there is no clear advantage to performing operative vaginal deliveries over C-section deliveries. In fact, operative vaginal deliveries in Canada lead to maternal injuries such as severe perineal and cervical lacerations in one out of every four forceps deliveries and one out of every eight vacuum deliveries.

As part of their study, Muraca and her co-authors worked with patients who have experienced the trauma caused by forceps and vacuum deliveries. One of those patients is Laura Ralph, who suffered a pelvic floor injury due to the use of forceps during her son’s delivery.

"I remember a caesarian delivery being discussed, but I don’t recall whether one was offered to me. I was also completely uninformed of the risks of caesarian versus forceps delivery," Ralph said in a media release.

"I often think of that conversation about caesarian delivery and wish someone had taken a few minutes to explain the pros and cons of each potential outcome with me."

Ralph lives with long-term complications as a result of her delivery. She had to have a medical device called a pessary inserted into the birth canal to provide support after pelvic prolapse, and was afraid to have more children because of the trauma she endured during her first delivery.

Infants are also susceptible to severe injury, although at a lower rate. One in every 105 infants delivered using forceps or vacuum in Canada suffers from some form of trauma, with brachial plexus injury – damage to a nerve in the neck that can lead to paralysis in the arm – the most common injury. Some injuries are severe enough to result in death.

According to the study, more than 35,000 infants are born each year in Canada with the use of these instruments, and since 2010, more mothers and birthing parents have been injured in these deliveries than in any other high-income country.

The most recent data published by the Organisation for Economic Co-operation and Development reveals Canada's injury rate in 2019 was 16.3 per cent, followed by 12.7 per cent in Denmark and 11.1 per cent in the United States.

WHY ARE RATES SO HIGH IN CANADA?

The analysis looks at several potential reasons for high rates of injury in Canada, but Muraca said some of the most influential factors go back to culture.

For instance, many of the countries that still commonly use forceps and vacuum instruments in delivery are predominantly english speaking countries. Muraca said that's because operative vaginal birth is a holdover from the British obstetric training model that goes back to a time when C-section births were riskier than they are today.

"So a lot of the obstetricians of the previous generation are really well trained in operative vaginal delivery because at that time it was just a prolific clinical option and there was less safety around caesarean delivery," she said.

While the safety of C-section deliveries has improved, in other words, obstetric culture in Canada has lagged.

There are methods obstetricians can use alongside forceps- and vacuum-assisted deliveries, such as making a specific incision between the vaginal opening and the anus during childbirth, that can help reduce the risk or severity of injury in these types of deliveries. While it's common in some countries for obstetricians to use these methods, they're less common in Canada.

Muraca said another issue in Canada is that maternal well-being after delivery isn't prioritized as highly as it should be. This isn't down to the attitudes of individual doctors, she said, but a systemic, cultural characteristic of medicine in Canada that needs to change.

"We have not prioritized preventing maternal trauma. It's been demoted in our hierarchy of maternal morbidity and these high rates of trauma have been normalized," she said. "If we’re not interested in acknowledging, recognizing or reducing maternal trauma, then we're going to continue to use these instruments without initiatives to ensure improved awareness and safety."

Because complications associated with these injuries – such as pelvic pain, sexual problems, and anal incontinence – can be a source of embarrassment and stigma for patients, and because they normally emerge after a patient has left the care of their obstetrician, Muraca said the issue isn't discussed in obstetric medicine in Canada as much as it should be.

Muraca and her co-authors hope their analysis will spur a national conversation about the high rate of trauma in forceps- and vacuum-assisted deliveries and the impacts those injuries can have on birthing parents.

In countries like the United Kingdom and Australia, national information campaigns have been set up to better inform birthing parents about the risks associated with operative vaginal births and the other options available to them.

Muraca wants to see a similar campaign launched in Canada, so patients are informed of the risks associated with all types of deliveries and able to make informed medical decisions for themselves.

"We’re calling for a national response to recognize the frequency and severity of these injuries in Canada," she said. "We have neglected to address them for far too long, and we are urging the maternity care community to make a commitment to reducing them." 

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