The Ordinary Doula Podcast
Welcome to The Ordinary Doula Podcast with Angie Rosier, hosted by Birth Learning. We help folks prepare for labor and birth with expertise coming from 20 years of experience in a busy doula practice, helping thousands of people prepare for labor, providing essential knowledge and tools for positive and empowering birth experiences.
The Ordinary Doula Podcast
E55: Instrument-Assisted Delivery
Discover the hidden world of instrument-assisted delivery and learn why it remains an essential, albeit less common, aspect of modern childbirth. Join, as we navigate through the fascinating history of forceps and vacuum use, tracing back to their peak in the mid-1900s, and understand why these tools are now reserved for specific, often unexpected scenarios. Through engaging discussions and personal stories, we uncover the critical decisions faced by parents and medical teams when labor takes an unexpected turn, and why safety is always the paramount concern.
You'll gain a deeper understanding of the precise circumstances that might necessitate these instruments, such as maternal fatigue or challenging fetal positions, and the rigorous precautions in place, including having a cesarean section as a backup. We'll talk candidly about the potential risks involved, such as tissue trauma and cephalohematomas, and why every birth is a unique journey requiring careful consideration. By sharing these insights and experiences, we aim to equip you with valuable knowledge to confidently navigate your childbirth journey or support a loved one in theirs.
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Show Credits
Host: Angie Rosier
Music: Michael Hicks
Photographer: Toni Walker
Episode Artwork: Nick Greenwood
Producer: Gillian Rosier Frampton
Voiceover: Ryan Parker
Welcome to the Ordinary Doula Podcast with Angie Rozier, hosted by Birth Learning, where we help prepare folks for labor and birth with expertise coming from 20 years of experience in a busy doula practice Helping thousands of people prepare for labor, providing essential knowledge and tools for positive and empowering birth experiences.
Speaker 2:Hello and welcome to the Ordinary Doula Podcast. I am your host, angie Rozier, and I am glad to be here with you today. You are probably here because you are preparing for labor, or you know someone who is, or you are helping someone who is, or maybe you're a doula who's going to help someone family member, however that might be. We like to explore all types of aspects and topics components of childbirth, delivery, postpartum lactation, kind of the whole big package of that little slice of life that's so pivotal and so awesome. We hope, we hope it's awesome. So today I want to talk about something called instrument assisted delivery. This is also referred to as operative vaginal delivery.
Speaker 2:I was recently reading in a forum that I follow on Facebook that's about birth work and doulas and childbirth a post about instrument assisted delivery, and I was surprised on there how many doulas had not seen that or were not familiar with what an instrument assisted delivery is. So let's, let's chat about that Now. I don't. I have never met a single client of mine that has ever said I want, I'm going to set out to have an instrument assisted delivery. This isn't something people plan for or strive to achieve or ascend to, but it's something, it's an option that may be presented at some point during the towards the end of the labor process. So if, if a delivery is being instrument assisted, we are at the end, right, we are like pushing the babies close to being born and for whatever reason, um there, and we'll talk about what the reasons are for whatever reason an instrument assisted delivery is offered. So let's talk about what those instruments are. We have forceps and vacuum. Those are the two instruments that, when we talk about instrument assisted or operative vaginal delivery, I don't see a ton of these. I used to see more of them years ago and they're kind of getting less common.
Speaker 2:And the type of instrument assisted delivery has shifted a little bit over the years as well. A lot bit actually. And I'm going to give you a tiny little bit of history. I could just do a whole podcast on this little component of history. But in the middle part of the 1900s, almost all deliveries were instrument assisted deliveries, like almost 100%. If you're giving birth in a hospital, women were drugged in such a way that they were not helpful to the process. Really, they were kind of draped and tied down in such a way that they weren't helpful. So almost 100% of deliveries, doctors would do an episiotomy, would place forceps and would pull babies out. So if you know someone who was born in the 1930s, 1940s, 1950s, 1960s, the high likelihood that their delivery included instrument assisted delivery. So we don't really do that anymore very much, which is a really great thing.
Speaker 2:So forceps used to be the tool of instrument assistance and they were actually created in France in the 1500s and it was a very widely held secret for a long time, only used for royalty, those poor royalty that had, and it was a new piece of technology that they were so excited to have and very protective of that knowledge and that secret for a long time. Um, and then they came, you know, they spread throughout the world and in the United States their use was extremely common for um a few decades in a time in our history when childbirth was what I call kind of the dark period. So anymore there's two instruments Vacuum is one and forceps are another. So let's talk about why we would need instrument-assisted delivery if this option should come up for you or someone you know during the delivery process. So, like I said, we're the babies close to being born. We've been pushing probably for a while. So that's called second stage.
Speaker 2:We're in second stage and there are a couple different reasons, a couple different scenarios that would prompt a provider to suggest instruments. One of those is that we have maternal fatigue Like this. This mom has been pushing for a long time. She's kind of tuckering out, running out of steam. Now she could do it like people. I'm so impressed and so repeatedly amazed by the strength of the human body and the human heart. But the effectiveness of pushing can decrease when someone is absolutely fatigued. So that might be a reason. Like mom's been pushing for a long time and we're maybe making progress, but slow progress, and so the offering of instruments, instrument assisted delivery, is something to kind of help in her time of fatigue. So the two instruments that would be offered are forceps and vacuum.
Speaker 2:The baby has like a few parameters have to be met in order for this to be an option. The baby has to be low enough for those to be safe. Long ago, like even 20, 30, 40 years ago, they would do high forceps where the baby was still pretty high in the pelvis and they'd go up and get the baby and pull the baby down. They don't do that anymore. They've realized ding, ding, ding, ding ding. That wasn't good for anyone.
Speaker 2:Internal structures of the female anatomy for babies to be going up, finding them, bringing them down. So babies have to be fairly low on their own. So the kind of the general rule for that is that the presenting part, which ideally of course is the head and the crown of the head at that not just the cap it but the crown of the head, has come down to a plus two. So that's kind of like ears-ish around about the baby's ears. So if we have a baby who's like a minus one, instruments are off the table, like that's not an option. So baby has to be descended pretty well for those instruments are off the table, like that's not an option. Um, so baby has to be descended pretty well for those instruments to be an option. Um, there's other parameters that exist. Babies have to be doing okay enough on their heart rate because likely when we add this intervention, um, baby's not going to love it. Uh, this is you. You know this isn't something babies are gonna absolutely say oh, awesome, that tickles great, let's do some more of that. Um, but these are designed to finish up the process.
Speaker 2:So another reason that instruments might be offered is the baby is malpositioned. Maybe mom's pushing with all her might, baby's coming down, albeit slowly, and if those is that instrument can just turn the baby a little bit. Maybe the baby's OP and we want to turn it a little bit of out of OP so it can fit better, or we need it just to descend a little bit more. Um, then instruments might be a method to kind of get baby into a better position. We also might have just a long pushing stage. Maybe mom's doing great, baby's doing great, like her energy is fine. But it's just if we're like looking at the several hours mark, you know, one to three hours for second stage or pushing is very common. But if we're looking at three, four, five hours, we've seen six, seven and this year saw nine hours of pushing, which is pretty remarkable, and still had a vaginal delivery. But if we're getting into those long hours, that might be a way to kind of get things moving along. So those are a couple of the reasons and the baby has to be in a pretty decent position as far as depth in the pelvis for that to be an option.
Speaker 2:So generally, providers today are going to prefer the vacuum over the forceps.
Speaker 2:Um, so the vacuum is a little instrument that really is just a vacuum. It's a suction cup. Um. There's a couple of different kinds, different brands, but some are, um, firm plastic, some are kind of softer, some have like a spongy foam in them, but it is designed to go on the baby's head and it does suction. There's like a suction they can have on the instrument. There's a little mechanism that shows how firm the pressure is and it comes with a little handle. So this vacuum goes onto the baby's head and then they make sure it's firmly applied and they can then pull the baby out with the handle or pull the baby down with the handle. If a baby has a ton of hair, like this really awesome head of hair, that vacuum's not really gonna stick to anything. So even if they try vacuuming, it might not work on some heads. Um, if there's really squishy cap it, they might be kind of concerned about hooking to you know attaching onto that, they want a good deal of the crown of the head um available.
Speaker 2:So we have more of the head Um. Forceps are metal and vacuum, are like one use things, like they're disposable basically. So they open them from a you know, a sterile package, they use them, they're done Um forceps. Babies can be a touch bit higher with forceps Um, and they are a reusable instrument that gets of course sterilized um between uses in an autoclave and then put in sterile packaging. But they are metal kind of tongs or spoons if you will. There's different kinds of forceps and they slide in to the vaginal opening and go around the baby's head hook to each other and also a handle is fashioned after that, you know, at the end of them. So these tongs go in cup on the baby's head hook together and then creates a handle for the provider to pull on. Like I said, sometimes we just rotate a baby into a better position with one use of an instrument like one pull. Sometimes we just rotate a baby into a better position with one use of an instrument like one pull. Sometimes we pull the baby just to the perineum so the baby's like right there, then we remove the instruments and then the baby's born over the perineum by the mom's own power and sometimes the instruments pull the baby entirely out altogether. Um, I will tell you, when a team is looking at doing instruments, they're, of course, very cautious. Everything has to work out well, but and they do have an operating room ready there's always an operating room at the ready when instruments are offered and used. Because if things don't go well, if baby doesn't respond well, if it didn't work, because it's not going to work, if this, if this last effort isn't going to bring the baby either down and out or down so that can then get out, then they have to go pretty quickly, sometimes really quickly, to a cesarean delivery, and there's other parameters around the use of those that limit the amount of times a doctor or provider can pull. And, by the way, this is not something midwives do. This is something that an OB would do. So if you have a midwife in a hospital and this is the direction things are going then an obstetrician would come in to do this. Your midwife would remain in the room and be with you. But this maneuver and procedure is done by an obstetrician and they're're of course, monitoring the baby's heart rate very carefully while they do this.
Speaker 2:No one prefers this right. This is not a preferred method of delivery, but we're going to talk about some cases where it might be preferred over other options. So they have a limited number of pulls. They can do three pulls with that, so pull through three contractions while monitoring the baby closely. They're not going to sit and pull and pull and pull for long periods of time, but it's a quick effort, a last effort and sometimes a very effective effort to get that baby either turned or descended enough to be born or born.
Speaker 2:Sometimes, as you can imagine, this increases what's coming out of the vaginal opening, especially with forceps. Like we have the baby's head and then we've just put something metal at that on the outside of the baby's head. So we've kind of made the diameter larger. Vacuum doesn't necessarily do that, but some providers will do an episiotomy before they place forceps. So that's a vaginal like a cut in the vaginal opening, a surgical incision to make it wider. Some don't. But the likelihood of tissue separation does go up with use of forceps, not as much with vacuum, but it does go up through use of forceps. So why would we want this? Like we said, if mom's just tuckered out and needs a little oomph, a little dip, push at the end. If baby's just little cattywampus in the pelvis, we can turn, rotate the baby, bring the baby down a little bit and it's a choice. Like nobody has to use instrument assisted delivery. Their other option is, if everything's fine, keep going a while, see what the body's own power does, and or do a cesarean.
Speaker 2:And I have seen clients who are offered an instrument assisted delivery and they decline. They say no, thank you, I'm not even going to try, I'd rather do a c-section. Others say absolutely we'll do anything to avoid a c-section. That's a individual and a case-by-case decision, of course. Kind of, look at the whole situation, the whole scenario, and see what's going on there. I have someone near and dear to me had a baby this summer which got to be a tough, really tough situation and five day long labor, five hours of pushing, a lot more interventions than this person had originally planned on, and after five hours of pushing the doctor offered instrument assisted delivery. The mom declined and said Nope, I'd rather take risk to my body than to the baby's body, I'd rather do a C-section. I don't know that I would make that same choice for myself or my baby. But again you got to look at the whole picture and every situation is very different. But it is an effort to avoid a cesarean, which is, of course, major abdominal surgery for the mom, recovery, everything that goes with that, additional risk factors in the future that come from cesarean delivery. Sometimes I have seen this too, where we do an instrument assisted delivery and we wished we would have done a C-section, we wish we would have chosen a C-section, assisted delivery and we wished we would have done a c-section, we wish we would have chosen a c-section. And this is one of many indicators where we make the whole team. The whole team makes the best decisions that they can in the moment with the information that they have. So this includes the person having a baby, those supporting her, the provider as well.
Speaker 2:But sometimes there's been pretty severe tissue trauma that has pretty lasting impacts after use of forceps. Sometimes there has been injuries to babies. When we look at vacuum, there can be cephalohematomas, which is a pretty like. The diameter of a vacuum is probably like I don't know six, seven centimeters and some babies will have a pretty good size hematoma, which is a looks like a giant blood blister. A bruise could cause internal bruising. Bleeding on the baby's head could increase likelihood of jaundice because we have some release of red blood cells are bleeding on the inside. I can definitely tell when a baby's been born by instrument.
Speaker 2:When we go to breastfeed that baby makes a unique kind of cry. They like every, they have a headache kind of, if you will. When the babies make a suction with their mouth, there's suctioning going on, there's a pressure change in their head. And if they have a hematoma or they have been delivered by instruments, you can tell they kind of whimper and cry when they try to make a seal and a latch at the breast for that first little while Healable. Yes, babies born by forceps have been known to have marks on their face. It's very rare. Some have had nerve damage. Like, depending on where the forceps are placed, there could be nerve damage.
Speaker 2:And then we also get into the pressure that is applied on the handle. The handle that's, you know, created, that handle created for pulling. There's an incredible amount of pressure put on that baby. And guess where that pressure is being put? It's, of course there's something on the baby's head, at the pressures on their neck. So those tiny little neck bones, you know, I've spoken to chiropractors and infant chiropractors over the years and, gosh, they want to see those babies right away. Or craniosacral therapists to release a lot of that pressure and kind of get babies back back in alignment and undo some of the trauma that might have been done to their bodies during the birth process. That adds quite a bit more pressure and I've seen some pretty traumatic traumatic to me, maybe not traumatic to the client, but traumatic to me instrument deliveries where we've got a provider, a grown man, grown woman, just pulling with all their might, trembling arms, to get that baby out.
Speaker 2:I've seen some doctors place forceps or try to say I'm not comfortable with this placement, let's move to a C-section. I've seen some pull once and vacuums, by the way, can pop off. So they also get a limited number of what we call pop-offs, like if they pull and the suction didn't keep the vacuum on the baby's head, they can only work with two or three pop-offs before they also call a C-section. So something definitely to be aware of. Every time there's an instrument assisted delivery I am going to really suggest not force, because that's not my role, but really suggest that that baby gets some quality body work done pretty quickly, that that baby gets some quality body work done pretty quickly, and mom too, whether that's pelvic floor PT afterwards to help everything to recover. So that's kind of the low down.
Speaker 2:On instrument assisted delivery, again we have vacuums, forceps, and vacuums are preferred. Some of the information that I've recently researched says one in eight deliveries in the United States are done by instrument assisted delivery. I feel like that's a little high. I probably see, I don't know, one in 20 is what I feel like, just anecdotally, like thinking back on the bursts that I've been at, you know, kind of recently, well, over the last 20 years too, and so, like I said, some people regret it, some people are very grateful for that because they did avoid a c-section.
Speaker 2:So, taking into account that this may come up, I just kind of want you to know what the options are. Hopefully it's not a decision you have to make and not a decision you're faced with, but kind of want you to understand what that means, what that entails. So, if this comes across your situation and your realm of awareness, that you kind of understand what's going on and can make a decision from there, um, I'd love to hear what, what you um, what you think about this, if you want to visit us um at birthlearningcom and connect with us Love to hear any stories you have about instrument assisted deliveries. There's a lot, yeah lots of different birth. I'm a birth story junkie so I'd love to hear your stories. But now you have maybe a little more information than you did and hopefully that's not something that you need to make a decision about in your labor and birth. But we want empowered birth and knowledge is power and so when you know all your options, you have options.
Speaker 2:Thank you so much for being with us here today on the Ordinary Doula, and hope you have a great day today. I don't know where you are or when you're listening to this, but it's a beautiful, crisp fall day here when I'm recording this and I hope you can feel the change in the air. That's that's here this season. Hope you have a good one and we'll see you next time.
Speaker 1:Thank you for listening to the Ordinary Doula podcast with Angie Rozier, hosted by Birth Learning. Episode credits will be in the show notes Tune in next time as we continue to explore the many aspects of giving birth. Thank you.