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This week, I continue to ponder assisted/instrumental childbirth. What has it looked like, and what does it look like in Sweden? Who is authorized to perform an instrumental delivery?
Within the midwife's role, we primarily discuss responsibility for a regular, spontaneous vaginal delivery, but when should the doctor be called? Can the midwife decide to use forceps independently? What should she do if the doctor is occupied and cannot arrive?
Instrumental Delivery
In Sweden today, approximately 100-110,000 children are born each year. However, it appears that the rate of childbirth is slightly declining in the country at the moment. The number has decreased somewhat in recent years.
Recent studies show that around 6% of children are born through an "assisted delivery/instrumental delivery." Vacuum extraction is more common among first-time mothers. About 11.5% of first-time mothers give birth with the assistance of vacuum extraction, compared to 3-4% among mothers who have given birth before.
The alternative to vacuum extraction is to use forceps or perform an emergency cesarean section.
Forceps Delivery
So, what are forceps, and is it really used in Sweden? Let's begin by noting that forceps delivery is much more common in other countries.
We must remember that the vacuum extractor is a Swedish invention and is therefore more common here. It's often said that the vacuum extractor is gentler on the woman but harsher on the fetus.
With forceps, it's the opposite. There are significant forces involved, and the primary risk of injury is to the woman, in my opinion. Forceps are used to assist in the delivery of the baby.
I, having worked in the delivery room for nearly 40 years, can use forceps. My younger colleagues who come after me can hardly use them, and forceps delivery is uncommon in Sweden today.
Today, forceps are an instrument used when nothing else works, and those who use them usually have little experience, making this very risky.
The question is whether it should really be this way. Or should forceps be used in somewhat calmer situations to be able to do it when it's an emergency? Some might think so.
The forceps used in childbirth consist of two halves. At one end of these two forceps halves, there are components called "spoons." These spoons are bowl-shaped so that they can encompass the baby's head, much like two hands.
The forceps halves are brought together and "locked" when the forceps are placed around the baby's head. Once the spoons encircle the baby's head, you can then gently pull the baby out.
The advantage of forceps is that they can be used even when contractions are weak or absent. In contrast, vacuum extraction requires the woman to assist by pushing.
The disadvantage of forceps is that they involve much greater forces than vacuum extraction. With some bad luck, these forces can potentially harm both the mother and the baby.
With forceps, it is also possible to correct the baby's position. In such cases, a different type of forceps (straight forceps) is used, but I have never seen this used in childbirth in Sweden. However, I have seen it in other countries where the practice of using forceps is much more common.
The Midwife's Role
Until the mid-18th century, all deliveries in Sweden took place in homes. Those who assisted mothers were practically always untrained older women who had experience giving birth themselves. They were called "jordemor" or "jordegumma," among other terms.
In 1697, the book "Then swenska wälöfwade jordegumman" was published. This was the first textbook for midwives and, in fact, the first Swedish textbook in the field of medical science.
In the preface of the book, it was written that all other sciences and arts must be learned, but
"a midwife is immediately a complete master, and her entire education often consists of a few words, namely what one midwife says to another. You can do it as well as I can, you sit alone in front of the woman and receive the baby when it comes."
Considering the jordegumma's total lack of education, they were prohibited from using tools, including forceps.
In 1775, the "Publica Accouchementshuset" (later known as the "Allmänna Barnbördshuset") was established. One of the main reasons for setting up a maternity hospital in Stockholm was to provide better opportunities for training in the art of childbirth for future doctors and midwives.
The education at the Allmänna Barnbördshuset improved the availability and training of midwives throughout the country. In 1822, it was considered acceptable to train midwives to use forceps independently, but it required a so-called "Instrument degree."
The arrival of forceps changed the situation so that it was possible to save the baby if one didn't wait too long to intervene in a stalled delivery. Before the possibility of forceps delivery, people simply waited for the baby to be born spontaneously, often for days. Many babies died in these prolonged deliveries.
With forceps, it became possible to save both the mother's and the baby's lives. Over time, the indications for using forceps expanded to include cases where the mother was in a life-threatening situation for other reasons, such as severe illness, fever, severe bleeding, and more.
The knowledge and right of midwives in Sweden to use instruments were unique in Europe, tailored to Sweden's geography and the distribution of its population in the long country.
However, the right for midwives to use forceps was revoked in 1919, with the justification that they so rarely had the opportunity to use them that they couldn't maintain their competence.
In modern obstetric care, midwives cannot apply forceps. Nevertheless, they can still place a vacuum extractor under a doctor's supervision.
Sweden's Parliament (Sveriges Riksdag)
I can tell you that when I began my career as a young doctor, I couldn't use a vacuum extractor. At that time (in the 1980s), midwives were still independently applying vacuum extractors in labor.
I sometimes look back and think it was fortunate that they could. I was the only doctor on call, and I couldn't do it. Later, I learned how to use vacuum extractors from the midwives.
What do Swedish laws say? Who is allowed to use a vacuum extractor according to the law?
According to the regulations for midwives (SFS 1955:592), it is not permitted for a midwife to use a vacuum extractor. The wording of the regulation in this regard is as follows:
"A midwife may only perform obstetric procedures upon the order of a physician or in cases where such an order cannot be awaited. However, she may not perform any obstetric procedure other than those that are done with hands or that concern the extraction of a low-lying fetal head with forceps."
Among experts, it is considered that the text is outdated and should be concluded with "forceps or vacuum extractors." This is because the use of vacuum extraction has become increasingly common, and midwives learn this method during their training and are reasonably proficient at it.
In many places, however, the regulation is interpreted to mean that it is obvious that midwives should be allowed to use a vacuum extractor because forceps, a riskier intervention, is permitted under the regulation.
Practices vary between different hospitals and different parts of our country.
When should we use a vacuum extractor/forceps?
For...
Threatened fetal distress
Weak contractions
Exhausted mother
Prolonged second stage of labor
Fetal malposition correction
Contraindication for maternal pushing (e.g., heart failure, high blood pressure, severe eye disease)
Requirements:
Fully dilated cervix
Ruptured fetal membranes
The head must be engaged in the pelvis, meaning the largest diameter of the head should have passed the level of the ischial spines.
No more than 1/5 of the fetal head can be palpated above the symphysis pubis.
If possible, perform...
Traction
This involves pulling down the fetal head to the pelvic floor. Then, the midwife can take over and deliver the baby during the last contractions with a slow delivery.
Traction is associated with fewer serious tears than extraction. You can leave the vacuum extractor in place until you see that the baby's head is not slipping back.
Abort the extraction and consider converting to a cesarean section in the following cases:
No progress after 3 consecutive traction attempts
2 pop-offs
If the woman is not expected to be delivered within 15 minutes (at most 20 minutes), including the time of attachment.
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Manual Rotation of the Fetus
This is a technique that I primarily learned during the studies I conducted in Tanzania.
In Tanzania, access to cesarean sections was limited, and vacuum extractors were not used (due to issues with equipment and lack of knowledge). Then, this was an alternative that, in my opinion, we use far too infrequently in our Swedish obstetric care.
We've previously discussed that when the fetus descends in a wide presentation (looking up at the ceiling instead of down at the floor when being born), it's harder to come out. The fetus comes down with a larger portion of the head's circumference, making it more challenging to deliver.
The occasions I have tried this technique are primarily when the fetus descends in a wide presentation, almost hanging over the mother's pubic bone.
In a manual rotation, the entire hand is inserted into the vagina to grasp the fetal neck. Then, pressure is applied with the thumb against the fetus's large fontanelle (to get the fetus to flex its neck/head slightly).
Afterward, an attempt is made to assist the fetus in rotating to an anterior position while the mother pushes. It's crucial to know in which direction the fetus naturally tends to rotate and simply facilitate it.
I have done this several times, and it is easier to succeed when the woman has previously given birth.
Is anesthesia needed? Some women may find that nitrous oxide is sufficient, while others may require a perineal nerve block. The most important thing is to communicate with the woman and explain what you intend to do.
More on this topic will follow next week.
/Doctor Eva
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