Assisted Birth

Most babies are born without any need for assistance, but there are times when assistance may be required for the safety of mother or baby. 

Using instruments (the vacuum cup or forceps) to assist birth may be necessary to avoid a caesarean section. In Australia and New Zealand, almost one baby in ten will be born with the assistance of instruments, and this is most common in a first birth.  

There are many reasons why help with the birth might be needed.

The commonest reasons are:

• your baby is not making progress to come through the birth canal as it would normally be expected
• there are concerns about your baby’s wellbeing and the birth must happen more quickly
• you are unable to continue pushing, or have been advised not to push during your birth
• you might not be able to push effectively, for example,if you have had an epidural for pain relief you may not have the sensation to push

Vacuum birth
A Ventouse or vacuum extractor uses a soft cup placed on the baby’s head. When the uterus contracts and you push, your doctor gently pulls on the cup to assist the baby to come through the birth canal and out of the vagina. More than one pull may be required.

Forceps birth
Forceps are smooth instruments with two curved spoon-shaped blades that hold and protect the baby’s head during delivery. As with the vacuum extractor, your doctor will help the baby come through the birth canal when you push during a contraction. More than one pull may be required.

What happens at the time of the birth?
Prior to your baby being born, the doctor will examine you to confirm that your cervix is fully open and to determine the exact position of the baby in the birth canal. The doctor will explain the procedure and gain your verbal consent. An assisted birth is sometimes performed in the operating theatre - this is usually done if it is thought that a caesarean birth might still be required.

Pain relief will be used, and this may involve the use of either local anaesthetic injected in and around the birth canal, or sometimes with an epidural or spinal (regional) anaesthetic. Most of the time you will also have an intravenous drip in a vein in your arm to give you fluids and medication.Your legs are also usually placed in supports to allow the doctor to assist the birth.

Your bladder will be emptied with a thin tube called a catheter, and sometimes this will stay in place for a brief period after the birth. Another final check of the baby’s position will be made prior to either the Ventouse or the Forceps being applied. The midwife will monitor the baby’s heart rate, as well as assisting you and the doctor in timing your contractions and pushing to maximise the chance of being successful: an assisted birth is a team effort.

An episiotomy - a cut in the perineum (the tissue between the vagina and anus) - may be used to allow the baby to be born. This is also done to minimise any tearing or trauma. In many cases the baby will be born directly onto your chest and into your arms so that you will see your baby straight away. Sometimes a doctor or another midwife will be present to check the baby as soon as it is born. This is usually the case if the birth is performed in the operating theatre.

Ventouse or Forceps?

Both the Ventouse and Forceps are safe and effective, and each instrument has advantages and disadvantages. The choice of instrument will vary with the position the baby is in, the type of pain relief available, and the experience and preference of the doctor assisting your birth.

Recovery
Moving around – you will be encouraged to walk with assistance as soon as possible after the birth. This may be delayed by the use of an epidural but is important as moving around helps prevent blood clots forming in your legs. Try to move as much as possible, even if it is difficult or uncomfortable.

Bleeding – it is normal to have bleeding after birth, and in the days following birth the bleeding should settle.

Bladder & bowels – if a catheter has been placed in the bladder it will usually be removed within a day. Your bowels may take a few days to return to normal and you may be given a laxative to assist with this.

Vaginal tears/Episiotomy – a tear or an episiotomy will be repaired with dissolving stitches - these do not need to be removed. Use of ice packs, firm support and rest will help with healing and recovery.

Pain relief – discomfort is normal after any birth. Taking regular pain relief is very important to your recovery. Let your midwife know if you require any pain relief or anti-sickness medication. 

Full recovery – full recovery may take a few weeks and as part of that process you may be seen by a physiotherapist who can help and instruct with care of your pelvic floor.

Sexual function – you can resume sex when you feel comfortable, but it may take a few weeks for this. Remember that it is normal to take a number of weeks, even months, before you are ready to have sex.

Emotional – it may be good to have a ‘debriefing’ after your birth. You can use this opportunity to discuss the reasons for the assisted birth before you leave hospital with your doctor or midwife. You may even wish to arrange visits later, after you leave your hospital or birth centre.

Complications and risks
All births carry a risk of complications, and most assisted births do not have any additional problems. It is important to understand that an assisted birth is almost always undertaken because the risk of not delivering the baby is greater. However, there are three types of risk with instrumental birth that women should be aware of:

• risks to the mother
•  risks to the baby
• the attempt at instrument-assisted birth does not work, and an emergency caesarean birth has to be undertaken

Mothers might have some bruising and abrasions of the skin around the vagina, but this might not be any worse than a spontaneous birth. There is the chance of injury to the muscles of the pelvic floor, and in rare circumstances, these can affect the bladder or bowel function.

In some cases, use of instruments during birth can lead to bruising of the baby’s scalp or face. Very rarely, there can be an injury to a nerve in the baby’s face – in most cases this heals quickly and completely. There may be a collection of blood (haematoma) under the skin of the baby’s scalp. This is more common with a Ventouse. It does not affect the baby’s brain and will resolve with time. Jaundice is more common with this condition.

Shoulder dystocia occurs when an assisted delivery allows the baby’s head to be born, but the baby’s shoulders do not come out. The doctor delivering the baby will take steps to help the shoulders be born, and this can be frightening. Shoulder dystocia can be difficult to predict, but occurs when a large baby with a large body is born. Although it can happen with a normal birth without instruments, it is more common with an assisted birth.

In extremely rare cases, there can be a fracture of the baby’s skull or brain haemorrhage. This is more likely if the assisted delivery has not been successful and a caesarean must be done to deliver the baby. Spinal cord injury is extremely rare.

Caesarean section
When the baby’s head is very deep in the mother’s birth canal, it can be difficult to deliver the baby either way. It is important to understand that a caesarean section in this situation is not an easy option and not always an alternative to an assisted birth. In some rare cases, the doctor might try to deliver the baby with forceps or ventouse, but the baby will not come out. In this case a caesarean section will be required.  

Your obstetrician will never contemplate an assisted vaginal birth unless it is safe to do so. However, the final decision has to be made at the moment of delivery. Your doctor will always choose to stop trying to deliver the baby through the vagina if the clinical picture changes and it is considered too dangerous. 

Having continuous support during your labour will help minimise the chance of an assisted birth. You will have a midwife caring for you throughout labour, but another person you know and trust may also reduce the likelihood of an assisted birth.