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For years, doctors have been looking for ways to reduce the rate of cesarean section deliveries, as they can pose higher risks to mothers and babies. But the narrow focus on C-sections may have allowed an increase in complications during certain vaginal deliveries to go largely unnoticed, a new study has found.

The rate of obstetric trauma during operative vaginal delivery – those involving the use of forceps or vacuum – rose from 16.6 per cent in 2004 to 19.4 per cent in 2014 among women delivering their first child, says a study published in the Canadian Medical Association Journal on Monday. The rate among women with a previous C-section delivery went from 13.8 per cent to 18.7 per cent over that same period.

Rates of obstetric trauma were most pronounced among those women who had a forceps delivery: an increase from 19.4 per cent for first time mothers in 2004 to 26.5 per cent in 2014.

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The most common sources of obstetric trauma were severe perineal lacerations and obstetric anal sphincter injury, which can lead to pain, sexual dysfunction and incontinence, among other debilitating side effects.

“These are high quality of life impairing complications,” said Giulia Muraca, lead author of the study and a postdoctoral fellow at the University of British Columbia’s School of Population and Public Health.

But the numbers don’t tell the full story, said John Kingdom, chair of the department of obstetrics and gynecology at the University of Toronto. Obstetricians are working on ways to increase the safety of forceps deliveries in order to make it possible for more women to deliver vaginally and avoid the risks and longer recoveries typically associated with C-sections.

“We care about these issues,” said Dr. Kingdom, who is also an obstetrician at Mount Sinai Hospital. “We don’t trivialize these issues at all.”

Some of the cases of obstetric trauma noted in the study might have occurred because the doctors didn’t have sufficient training. So the issue isn’t that forceps deliveries are inherently dangerous – it’s that doctors need to have the necessary skills and training to make those deliveries as safe as possible.

Gabrielle Cassir, an obstetrician in the maternal fetal medicine department at Mount Sinai, said it’s a challenge to ensure all doctors become experts at forceps deliveries because fewer women are having them. But training is the key to ensuring that forceps, vacuum and other modes of assisted vaginal delivery are available.

“It’s very important to find a way to get that training in for younger doctors,” Dr. Cassir said.

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And since the appropriate use of forceps may help prevent unnecessary C-sections, hospitals are moving to ensure the younger generation of obstetricians gets the necessary training. For instance, Mount Sinai is about to launch a safe forceps program, Dr. Kingdom said.

In the meantime, Ms. Muraca said it’s important for more women to be aware of the potential risks. Many who have suffered obstetric trauma and are dealing with side effects such as incontinence are typically reluctant to talk about it openly, she said. And many doctors and health policy-makers may be concerned that if women hear about bad outcomes involving instrument-assisted vaginal delivery, they may be more likely to choose a C-section. Ms. Muraca said despite this, women need to hear the unvarnished truth so they can make an informed birthing decision.

“We can’t really choose what information we give them,” she said.

The study looked at data from nearly two million singleton births that occurred in Alberta, Saskatchewan, Manitoba and Ontario from 2004 to 2014. Over the study period, the rate of operative vaginal delivery was 18.2 per cent and the C-section rate was 26.6 per cent in women having their first child. The overall rate of obstetric trauma was 7.2 per cent among first-time mothers, 2.2 per cent in women who had previously given birth and 2.7 per cent among women who had previously had a C-section.


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