Maternal injuries happening at ‘absurdly high’ rate in Canada during labour. Why?

The use of forceps and vacuum delivery tools during labour has resulted in an alarmingly high number of maternal traumas in Canada, such as severe perineal and cervical tears, according to a recent report.

Published in the BMJ on Thursday, an analysis spearheaded by McMaster University revealed that among high-income nations, Canada has the highest incidence of maternal trauma stemming from deliveries involving forceps or vacuum extraction tools.

“Of the most distressing complication of those injuries is fecal and anal incontinence. That’s the involuntary loss of liquid and solid stool,” explained the paper’s lead author, Giulia Muraca, an assistant professor in the departments of obstetrics and gynecology and health research methods, evidence and impact at McMaster University.

“We only know the tip of the iceberg when it comes to those complications because they’re incredibly stigmatized. Women are ashamed,” she told Global News.

Forceps and vacuum instruments are used in childbirth to assist with the delivery of a baby when there are complications, Muraca said. Examples of this include fetal distress, prolonged labour or the personal choice of either the patient or the doctor.

If possible, it can also be used as an alternative and less invasive method than performing a caesarean section.

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But all three methods of delivery come with risks, warned Dr. Amanda Black, a professor of obstetrics and gynecology at the University of Ottawa and president of the Society of Obstetricians and Gynaecologists of Canada (SOGC).

“Be that just a spontaneous vaginal delivery or an assisted vaginal delivery or a caesarean section … they all have potential risks associated with them,” she said. “Caesarean sections performed in the late stages of labour are associated with additional risks as well, including the risk of maternal hemorrhage.”

Although forceps and vacuum instruments can be used when appropriate, Muraca and her colleagues wanted to investigate their safety as an alternative to reducing ceasarean section rates.

“The most compelling finding was these rates of trauma that we were not expecting,” Muraca said.

Each year, more than 35,000 infants are born after attempted operative vaginal delivery in Canada. The report found that one in four women who underwent forceps deliveries experienced significant maternal trauma, while one in eight of those undergoing vacuum deliveries also sustained severe injuries.

“And mainly these are obstetric sphincter injuries,” she said. “These are lacerations between the vagina and the anus that aren’t superficial. They involve both the external and internal anal sphincter. So these are severe injuries. They’re not a stitch and you go home.”

Other trauma incidents include injury to the bladder, uterus, pelvis and organs surrounding it, she said.

And many women who endure these injuries believe it’s normal and “it’s not something to complain about,” Muraca added.

The researchers of the report collected and analyzed data from the Organization for Economic Co-operation and Development (OECD) between 2010 and 2019 (the most recent data available).

In 2010, they found that Canada has had the highest rates of maternal trauma during forceps and vacuum deliveries when compared with other high-income countries.

And in 2019, data showed Canada with the highest rate at 16.3 per cent, followed by Denmark at 12.7 per cent and the United States at 11.1 per cent.

“This means for 10 years we’ve been on this international stage of having these abysmal rates of these injuries. And there’s nothing we’ve done about them,” Muraca said.

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The rates of obstetric anal sphincter injury in Canada, the research showed, are almost three times higher than in the United Kingdom, which has rates close to the average for countries in the OECD.

The report also found rates of obstetric anal sphincter injury are higher with forceps delivery than with vacuum delivery, and Canada uses forceps more often than many other countries.

Obstetric anal sphincter injury is associated with an increased risk of pelvic floor disorders, pelvic pain and sexual dysfunction, the report stated. Fecal and anal incontinence are direct complications of these injuries and can have devastating effects on social, psychological and physical well-being, it added.

Because of these risks, European countries have abandoned forceps altogether.

However, Black said there’s no desire to abandon assisted vaginal deliveries, like forceps, in Canada.

“Sometimes the safest thing for both mother and baby is to deliver the baby quickly with a vacuum and forceps,” Black said. “I don’t see a worldwide push to try to ban the use of forceps or vacuums. In fact, it’s the opposite. There’s a push to try to continue to decrease the rate of caesarean deliveries.”

There are several reasons that may contribute to Canada’s high rates of maternal injuries, but it’s only speculative, Muraca said.

“One of the reasons I think we have higher rates is because we use forceps deliveries relatively more than other places, and forceps deliveries have higher rates of these injuries than a vacuum,” she said.

Another reason may be linked to episiotomy. This is when a surgical incision is made in the perineum (area between the vaginal opening and the anus) during childbirth to help the delivery of the baby.

Although an episiotomy was once a routine part of childbirth, that’s no longer the case. However, the researchers said observational data has shown a specific time of episiotomy (on an angle) can decrease rates of injuries when using forceps or vacuums.

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“It’s actually shown that it is helpful. And so you see in places like the U.K. and Australia … their guidelines say use it, especially with forceps. And in Canada, our guidelines say to use these in a restrictive way,” she said.

Canada has “shied away” from routine episiotomies over the years, Black said. But, she said, in some instances, “maybe that is something we should be considering.”

According to the report, another potential contributing factor to increased rates of injury in cases involving forceps and vacuum delivery is inadequate training.

Canadian studies show that the use of these instruments for vaginal delivery has declined. Therefore, there is likely diminishing expertise in this field.

“Without a doubt, we’re doing fewer operative vaginal deliveries than we had in the past,” Black explained. “And that’s why we need to make sure that we’re invested in training people to do these correctly and with best practice in mind so that we can try to mitigate any other potential risks or side effects that could be associated with the delivery.“

Regarding the lower rates in the U.K., the report attributed this success to a national health campaign in which medical experts developed a “care bundle” aimed at reducing injury rates, not only for forceps and vacuum deliveries but for all delivery methods, Muraca explained.

A 2020 study published in Obstetrics and Gynecology found that the introduction of these care bundles — a multifaceted approach to reduce obstetric anal sphincter injury (OASI) rates — worked.

“We need to do the same,” Muraca said. “This is not about pointing fingers. No obstetrician or maternity care provider wants anything other than having a healthy mom, a healthy baby and a satisfied family.”

She urged health-care professionals to recognize that the injuries are happening at an “absurdly high, unacceptable rate.”

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An essential step is ensuring that women are properly informed about the potential risks associated with forceps, vacuum and caesarean deliveries.

“Talk about it, be transparent about this with birthing people and do that well before they’re in labour, These are things we can do that we could try to reduce these rates in our country for Canadian birthing people,” she said.

However, it may be difficult to counsel a patient on every potential outcome that may come up over the course of their labour and delivery, Black warned.

“The onus is really on health-care providers to ensure that they work with patients over the course of the labour to address things as they’re arising … so the (patient) understands what’s happening to them.”