Does Forceps Birth Cause Prolapse?

First of all

What is Prolapse?

Prolapse is defined here on the NHS website as “when one or more of the organs in the pelvis slip down from their normal position and bulge into the vagina”. You may or may not feel this bulge, depending on how low the prolapse is in the vagina.

The prevalence of pelvic organ prolapse is reported in the research as being (depending which studies you look at) between 15 and 48%.

What is a Forceps Birth?

It’s probably one of those things that almost always comes up in my Gentlebirth Workshop as something that women REALLY don’t want to happen in labour. Why is this? Well, usually an episiotomy is performed to facilitate the use of the forceps.

First of all, nobody wants to have a surgical cut to the perineum if they can help it. Second of all, many women are worried about the implications an episiotomy or forceps birth may have for the pelvic floor and bladder health and a healthy sex life once they’re ready.

So, is it true? Does episiotomy really take longer to heal and have a negative impact on sexual functioning for women? The research seems to suggest that it does. (You can read more about episiotomy here). And Are you more likely to have pelvic floor damage and dysfunction after a forceps birth? The answer is probably. The reason is because of a pelvic floor muscle problem called levator avulsion.

 

What is Levator Avulsion?

A levator avulsion is where part of your pelvic floor muscle becomes detached from the wall of your pelvis. This causes the natural gap in your pelvic floor muscles to become wider and your muscles may not function as well as they should. Sue Croft, an Australian pelvic health physiotherapist explains levator avulsion very well here.

 

What Causes Levator Avulsion?

The most common risk factors from the research are:

Age
Professor Hans Peter Dietz, a leading researcher in the field of prolapse and levator avulsion in particular, is very clear that a mother’s age when her first child is born affects the risk of having levator trauma. At age 20, the likelihood of levator avulsion is under 15% but rises to just over 50% at age 40. However, it’s not all bad news – other research found that “Most levator avulsions……seem to be caused by the first vaginal birth. Subsequent vaginal deliveries after the first were unlikely to cause further levator trauma”.

Forceps Birth
Professor Dietz and others have found that levator avulsion is much more common in women who have birthed their babies with the help of forceps. In fact, the rate of levator trauma is almost tripled for these women compared with women who have not had a forceps birth. However, it’s important to remember that, though caesarean birth is protective against bladder and bowel prolapse, it doesn’t reduce the risk of womb (uterine) prolapse. It’s seems also that vacuum birth does not increase the risk of levator trauma and pelvic organ prolapse any more than spontaneous vaginal birth does.

Why Does Levator Avulsion Matter?

Unfortunately much of the research seems to agree on this; having a levator avulsion injury increases your risk of pelvic organ prolapse. The research suggests that it may increase the risk of significant prolapse 2-3 fold, depending on the size of the gap in the pelvic floor muscles.

What Else Increases The Risk of Pelvic Organ Prolapse?

  • Family History
    Your family history on your maternal side can be an important indicator of your risk of developing prolapse and you may have this information even before you have your first baby. This can help you to formulate birth preferences and possibly make decisions in labour.
  • BMI
    Being overweight seems to be a less important predictor of your chances of developing prolapse. However, it is something that you can change (albeit often with a LOT of effort!) so maintaining a healthy weight may be one of the ways you can stack the odds in your favour of preventing the development of prolapse.
  • Age
    Being post menopausal of course increases the risk of prolapse due to hormonal changes. So although you can’t change this, you can be more mindful of being more gentle with yourself at this stage when it comes to the types of exercise you engage in as well as other lifestyle factors.
  • Number of Births
    This may or may not be a factor that you can (or will want to) change.
  • Chronic Constipation
    This is a very modifiable risk factor and as such, should be assessed and treated early. (I will write a blog post on this soon!)
  • Chronic Cough
    This may be due to asthma or another lung condition, and like constipation should be assessed and treated as early as possible. If it persists having visited your G.P, it is very worthwhile to see a respiratory consultant.
  • Connective Tissue Disease
    Conditions such as Ehlers Danlos etc can very significantly affect pelvic organ support and, depending on your other risk factors, it is be important to talk through the pros and cons of vaginal birth with both your obstetrician and your rheumatologist.
  • Heavy Manual Labour
    This is a significant risk factor for some women. Nowadays not many of us are involved in heavy manual jobs, but some women find themselves as a carer for an elderly relative or disabled child, which can be very physically demanding.

It’s important that women who are involved in physically demanding work like this have access to, and are trained in the use of assistive devices like sliding sheets, hoists, transfer boards or any other aids to reduce the amount of heavy lifting involved.

Deciding on Instrumental Birth or Emergency Caesarean in Labour

When you’re in labour and it’s an emergency is definitely not the best time to be discussing your options with your obstetrician so I would suggest chatting through things at some stage during your pregnancy. Having Birth preferences can be a great way of opening a discussion and having your views heard on various birth interventions. It’s great to know too what your care provider’s rate of forceps births is.

Pros & Cons of Instrumental Birth v Caesarean at full dilation

The Royal College of Obstetricians & Gynaecologists (RCOG) describes the cons of caesarean birth at full dilation compared to instrumental birth as:

– Increased risk of major post partum haemorrhage
– Increased risk of prolonged hospital stay
– Increased risk of neonatal intensive care unit admission for baby

 

The pros of caesarean birth are not mentioned but we know that caesarean birth is associated with decreased risk of levator trauma, perineal injury, bladder and bowel prolapse as well as pelvic floor dysfunction.

 

The pros of operative (instrumental) birth according to RCOG are:

– Decreased need for analgesia
– Quicker healing
– 80% increased chance of vaginal birth on next pregnancy

 

The cons include:

– Increased risk of perineal injury
– Increased risk of incontinence
– Increased risk of pelvic floor dysfunction and/or prolapse

 

Even if you’d rather opt for a caesarean at full dilation than have a forceps birth, it may happen that there just isn’t time. In this case, you’ll want to know who exactly will be using the forceps. Research has shown that outcomes are better for women if the person using the forceps is experienced, competent and confident in their use.

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