In our obsession with lowering C-section rates, there has been much handwringing over the lost art of forceps deliveries. The dramatic rise in C-section rates has been caused in part by the fact that many deliveries that would have been accomplished by forceps have become C-sections because of our reluctance to use forceps. But there’s a good reason why forceps have gone out of fashion: they are much more likely to harm a baby than C-sections.
This hideous case is just one example: Mom blames newborns’ death on doctor’s use of forceps.
[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]We shouldn’t lament the passage of forceps into history [/pullquote]
A Long Island obstetrician allegedly used forceps so aggressively during a delivery that he severed the infant’s head internally from his spine, according to court papers.
A devastated Megan Stirnweiss, 23, says her nightmare began when she went to Southampton Hospital in labor Dec. 30, in a last-minute decision after her home delivery became too painful.
What happened?
The doctor put forceps around the baby’s head and yanked, dragging Stirnweiss — who was holding onto the bars of her hospital bed — all the way down to the edge, court papers say.
Then “he pulled the forceps that he had around the fetus’s head, lifting [Stirnweiss] off the bed by the forceps around the fetus’s head, and shook her vigorously until the baby was delivered at 2:56 a.m.,’’ according to the lawsuit…
The baby — who “was internally decapitated” — was whisked away, the papers state.
As for Stirnweiss, she “suffered disruption, dislocation, tearing and lacerations of her internal organs and structures,’’ her suit says. She now “is in constant pain’’ and will “require reconstructive surgery,’’ the papers state.
The accompanying picture of the baby adds more detail for those who know where to look. While the doctor may or may not have used excessive traction, one thing appears indisputable; the doctor did not put the forceps on properly. Forceps are designed to rest over the baby’s cheeks. This baby has an obvious imprint of a forceps blade over his forehead, extending to his eye. The forceps application wasn’t even close.
This highlights a fundamental difference between forceps and C-sections. Forceps use requires far more skill than performing surgery.
As Atul Gawande wrote in a fabulous piece entitle The Score:
“Forceps deliveries are very difficult to teach—much more difficult than a C-section,” Bowes said. “With a C-section, you stand across from the learner. You can see exactly what the person is doing. You can say, ‘Not there. There.’ With the forceps, though, there is a feel that is very hard to teach.” Just putting the forceps on a baby’s head is tricky. You have to choose the right one for the shape of the mother’s pelvis and the size of the child’s head—and there are at least half a dozen types of forceps. You have to slide the blades symmetrically along the sides, travelling exactly in the space between the ears and the eyes and over the cheekbones. “For most residents, it took two or three years of training to get this consistently right,” he said. Then a doctor must apply forces of both traction and compression—pulling, his chapter explained, with an average of forty to seventy pounds of axial force and five pounds of fetal skull compression. “When you put tension on the forceps, you should have some sense that there is movement.” Too much force, and skin can tear, the skull can fracture, a fatal brain hemorrhage may result. “Some residents had a real feel for it,” Bowes said. “Others didn’t.”
Back when C-sections were considerably more dangerous than they are today, fetal injuries caused by forceps seemed like a reasonable trade-off for avoiding a procedure that might kill the mother. Once the C-section became as safe as it is today, harming a baby’s health and neurological function no longer seems like a reasonable risk.
It is important to note that there are different types of forceps deliveries. Outlet forceps, as the name implies, are used only when the head is extremely close to delivery. These forceps shorten the time to a birth that was going to happen anyway. They are often used to shorten labor when fetal distress is diagnosed and they rarely cause injuries.
Mid-forceps, in contrast, are used to deliver a baby that is stuck despite what appears to be a large enough maternal pelvis. They involve far more skill, far more traction, and far higher risk of injury. The most dangerous mid-forceps procedures are mid-forceps rotations. These are used to turn a baby in the unfavorable occiput posterior (OP or “sunny side up”) to the more favorable occiput anterior position and then traction is applied to deliver the baby. Not surprisingly, these procedures require the most skill of all and pose the most danger to both baby and mother.
The potential danger to the baby is obvious: fractured skull, neurological injury, and internal decapition (fracturing the top of the spine). The potential danger to mothers is also significant: far higher rates of anal sphincter injuries and subsequent problems with continence and sexual function.
Mid-forceps, and in particular mid-forceps rotations, are used to deliver babies that probably will not come out or will not come out alive if nature is left to take its course. If the baby cannot be delivered, the mother will die, too. So allowing a woman to push more than 3 or 4 hours in this situation won’t result in a vaginal delivery. The only choice is between forceps and Cesarean.
Most mothers and many obstetricians think it’s no choice at all. A C-section, which involves slightly more risk for the mother and virtually no risk to the baby, makes more sense than forceps, which involves very significant risks to the baby and risks to the pelvic floor of the mother.
Had this doctor opted for a C-section instead of forceps, both the baby and mother probably would have done fine.
Instead:
Stirnweiss, a cook for the US Coast Guard, said she and her husband kept their baby alive on machines for seven days so that his organs could be donated. A baby from Toronto, Canada, received Matthew’s lungs.
“He gave the ultimate gift of life,” she told The Post of her son.
Is this an indictment of all forceps?
Dr. Steven Goldstein, a professor of obstetrics and gynecology at NYU Langone Medical Center who is not involved in the suit, told The Post, “This is a terrible case.
“This is very sad, but this is not necessarily indicative of the way that forceps can and should be used,’’ he said. “Some forceps are still very safe.”
That’s true. Outlet forceps are very safe because the baby would have eventually come out vaginally in any case. But mid-forceps, the forceps procedures that have been replaced by C-sections, have major risks to both babies and mothers. No one should lament their passing into history or the higher C-sections rates that result.
