Action needed on Canada’s injury rate during forceps and vacuum delivery: Researchers

After years of presenting statistics about Canada’s high rate of injuries during forceps and vacuum deliveries, researchers at McMaster University published a paper in BMJ urging the medical community to do something about it. A quarter (25.3%) of forceps delivery and an eighth (13.2%) of vaccuum deliveries result in maternal injury, according to a study by Giulia Muraca and colleagues. Muraca, an epidemiologist, is an assistant professor in the departments of obstetrics and gynecology and health research methods, evidence, and impact at McMaster University in Hamilton, Ont. The most common maternal injury is obstetric anal sphincter injury. The consequences of these injuries often present five to fifteen years after delivery, when patients begin to experience symptoms including fecal incontinence. Read: Locum program launched to strengthen maternity care in rural B.C. The incidence of neonatal injuries is 9.6 per 1000 live births for both forceps deliveries and vacuum deliveries. “There’s an urgency to recognize, to be more transparent, and to enact some interventions to reduce these rates of injuries,” she said. “All of which is overdue.” By transparency, Muraca means that physicians should be clear when describing the benefits and risks of all possible modes of delivery. It needs to be communicated with patients in a balanced way earlier in the pregnancy. Often the data on injury rates with forceps delivery is aggregated with spontaneous vaginal delivery and vacuum delivery, making the risk appear lower, Muraca said. Patients need to know that with a forceps delivery, there’s a one in four chance of an anal sphincter injury. Read: Complication during childbirth: How to advise women who are at risk of recurrence Forceps and vacuum deliveries are still safe options in trained hands, said Dr. Modupe Tunde-Byass, an obstetrician and gynecologist focused on high-risk births at North York General Hospital. She told CBC News that people should learn about alternatives early in their pregnancy, including cesarian sections and episiotomies. In Canada, about 11% of deliveries of single infants are operative vaginal deliveries, with more vacuum deliveries than forceps deliveries, according to data analyzed by Muraca and colleagues in 2016. This is higher than in other countries, Muraca said. While people may not always have a choice about what type of delivery they’ll have, they still need to know about what could happen. Muraca hears from patients who say they feel deceived because they never knew about the possibility of injury. Knowing the risks may be helpful for patients who are planning future pregnancies. Someone planning to have four children may opt for an operative vaginal birth instead of a cesarian section because of risks with subsequent deliveries, yet a person planning to have one child may make a different decision, Muraca said. Family physicians can also encourage pelvic floor exercises or pelvic floor physiotherapy to lower the chance an operative vaginal delivery will be required. A 2022 CMAJ paper by Muraca and colleagues shows that no matter how many operative vaginal deliveries occur in centres across Canada, there remains a high rate of injury. “It’s high everywhere,” she said. “The rate is pretty consistent and pretty consistently high.” In a single centre, she noted, the number of maternal injuries during a forceps or vacuum delivery may seem low, but when physicians see the number on a Canada-wide scale it becomes clear that its a problem. Care bundles National quality improvement initiatives, or “care bundles,” could be a way to lower injury rates. These care bundles could include antenatal discussion about risk of obstetric anal sphincter injury and personal risk factors, informed consent for manual perineal protection during childbirth, consent for possible mediolateral episiotomy when indicated, Muraca said. There’s work to be done before rolling out care bundles to ensure they’re effective, usable, and acceptable to patients, physicians and midwives. The Canadian Society for Pelvic Medicine is working with other groups to develop care bundles, Dr. Jane Schulz told Matt Galloway on CBC’s The Current. Dr. Schulz is a urogynecologist and chair of the department of obstetrics and gynecology at the University of Alberta. She works in a pelvic floor clinic at the Lois Hole Hospitial for Women in Edmonton. More training for providers is another strategy to reduce injury rates. The International Urogynecological Association has a teaching program on providing care during operative vaginal deliveries. “A huge part is education,” Dr. Schultz said. This includes “making sure providers are aware what to look for and examining the area at the time of delivery after, and then if there is an injury, ensuring that the patient has access to care centres such as ours with our pelvic floor clinic.” Most tertiary centres have perineal injury or pelvic floor disorder clinics, she said. Since the publication of the 2022 paper, “we have a lot more support from the maternity care community,” Muraca said. More providers are willing to reflect on what can be done in their care centres and practices. “I think the BMJ paper is going to continue to work on that momentum.” “I’m more optimistic today probably than I’ve ever been that we’re actually going to see some improvements if we keep at this.” Highest in developed countries The first step to dealing with the high maternal injury rates is to acknowledge that they're not normal, Muraca said. Canada has the highest rate of maternal trauma during vaginal delivery where an instrument is used compared to other developed nations, according to data from the Organization for Economic Co-operation and Development. The most recent data show injury rates at 16.3%, compared to 12.7% in Denmark and 11.1% in the United States. Other countries, such as Australia and the U.K. already have national programs working to reduce the number of maternal obstetrical injuries. Comparing data between countries can sometimes be problematic in that it’s not always straightforward, Dr. Amanda Black, president of the Society of Obstetricians and Gynecologists of Canada, told CBC News. “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,” she said. The latest analysis was published in the BMJ in October. Read: ‘Deplorable’: Canadians believe the federal government should end routine birth evacuations

Action needed on Canada’s injury rate during forceps and vacuum delivery: Researchers

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