Maternity Pelvic Floor Research Women’s Health

High maternal injury rates in forceps, vacuum births in Canada need addressing: analysis

A new analysis published in the BMJ by researchers at the University of BC and McMaster University shows high rates of injuries with forceps and vacuum delivery in Canada that have been documented for over a decade without efforts to address them.

The paper was authored by a team of perinatal epidemiologists, obstetricians, community advocates, patient partners and urogynecologists, including St. Paul’s Hospital’s Dr. Roxana Geoffrion, co-author.

It calls for increased recognition, transparency and action to prevent these injuries.

National conversation around these injuries needed

As part of the analysis, the researchers present data from the Organisation for Economic Co-operation and Development showing that since 2010, Canada has had the highest rates of maternal trauma during forceps and vacuum deliveries when compared with other high-income countries. The most recent data from 2019 shows 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.

The researchers hope the analysis will spur a national conversation about these injuries and the impacts they can have on women.

Dr. Roxana Geoffrion

“Pregnant patients need to understand both short- and long-term complications related to vaginal delivery assisted by vacuum or forceps,” says Dr. Geoffrion, also an associate professor of obstetrics and gynecology at UBC. Her clinical and academic practice focuses on women with pelvic-floor disorders following childbirth trauma.

“Through this research, we hope to encourage more thorough conversations between patients and their maternity-care providers to establish informed consent for various modes of delivery during pregnancy and well before labour begins.”

The paper’s lead author, Dr. Giulia Muraca, a former postdoctoral fellow at UBC and now an assistant professor at McMaster University, says while benchmarking against other countries is informative, the key facts are about how this is affecting Canadians.

“More than 35,000 infants are born each year in Canada with the use of these instruments and maternal injuries are occurring at an alarming frequency.

UBC’s Dr. Sarka Lisonkova, associate professor in UBC’s department of obstetrics and gynecology, and Dr. K.S. Joseph, professor in UBC’s department of obstetrics and gynecology, and the School of Population and Public Health, are also co-authors of the paper.

Injuries have short, long-term consequences for women

Maternal trauma describes a group of injuries to the pelvis and surrounding organs that occur during childbirth, such as severe perineal and cervical lacerations. These injuries have several short- and long-term consequences, such as pelvic pain, sexual problems, and anal incontinence. One in four women sustains these injuries following forceps deliveries (25.3 per cent) and one in eight with vacuum deliveries (13.2 per cent).

“We’re calling for a national response to recognize the frequency and severity of these injuries in Canada. We have neglected to address them for far too long, and we are urging the maternity care community to make a commitment to reducing them,” says Dr. Muraca.

As part of the analysis, researchers worked with patients who experienced trauma caused by forceps and vacuum deliveries firsthand. One is Laura Ralph, who suffered a pelvic floor injury during her son’s delivery due to the use of forceps.

“I remember a cesarean delivery being discussed, but I don’t recall whether one was offered to me. I was also completely uninformed of the risks of cesarean versus forceps delivery,” Ralph says.

In the analysis, several potential reasons for these high rates of injuries are discussed, such as policies in Canada regarding labour interventions and challenges with training. However, the researchers caution against reflexive recommendations to increase training.

Improving informed consent needed

“If we expect these injuries to decrease by simply investing in the existing training paradigms, we run the risk of harming even more people and families, and further stigmatizing people with these injuries,” says Dr. Geoffrion. “Efforts to change the culture around these injuries need to take precedence, including improving informed consent practices, and engendering a culture in which these injuries are acknowledged as severe, avoidable complications.”

A version of this story originally appeared on the McMaster University website.