Caesarean delivery in the second stage of labour: Consider the value of a functionally intact perineum

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7571.753-a (Published 05 October 2006) Cite this as: BMJ 2006;333:753
  1. Michelle J Thornton, consultant colorectal surgeon (Michelle.Thornton{at}lanarkshire.scot.nhs.uk)
  1. Wishaw General Hospital, Wishaw ML2 0DP

    EDITOR—Spencer et al say that instrumental delivery may reduce the caesarean section rate in the second stage of labour.1 Although this may be important for the 2006 NHS budget—saving anaesthetic, operating theatre, and hospital costs in the short term—the longer term health outcomes and costs of a high forceps delivery are concerning and go unmentioned.

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    Recognised third and fourth degree perineal tears occur in 0.5-6% of vaginal deliveries in the western world.2 3 A further 30-44% are estimated to be unrecognised.1 One of the most significant factors, clinically and statistically, to be associated with perineal injury is an instrumental delivery.2 3

    Up to a quarter of women with a tear will experience faecal incontinence.3 Although perineal injury during childbirth may not be the sole factor for faecal incontinence, perineal damage increases its likelihood.3 The economic costs of faecal incontinence are large, lifetime cost estimates ranging from £7000 to £43 000, depending on treatment.4 The social implications are immeasurable. In a questionnaire of their personal birthing choices even female obstetricians chose caesarean section over an instrumentally assisted delivery.5

    To advocate obstetric management that has been declined by educated colleagues is worrying, particularly when the social and economic costs are so great and the idea of gaining valid informed consent is increasing.


    • Competing interests None declared.


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