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Am Fam Physician. 2004;70(11):2210-2211

Despite concerns about potential damage to the baby and the maternal pelvic floor, use of instrumental vaginal delivery has been proposed as one strategy to decrease the rate of cesarean delivery. To assess the effects of instrumental vaginal delivery on subsequent pregnancies, Bahl and colleagues studied women who had undergone the procedure.

The authors studied 283 women who had an instrumental or cesarean delivery at full dilation at two British teaching hospitals. Inclusion criteria were instrumental vertex delivery of a live singleton after 37 weeks of gestation or cesarean delivery at full dilation. Study participants were surveyed by mail three years after delivery to obtain information about subsequent pregnancies and deliveries. The primary interest was the method of delivery in subsequent pregnancies. Other outcomes measured included subfertility, early pregnancy loss, preterm delivery, and fear of subsequent pregnancy. Responses from the 133 mothers who had instrumental vaginal delivery were compared with responses of the 150 mothers who had cesarean delivery.

Women who had a cesarean delivery reported greater difficulty conceiving than women who delivered vaginally. Overall, 67 percent of women in the cesarean group and 79 percent of women in the instrumental delivery group achieved a planned pregnancy within three years. Of the 91 women who did not plan a further pregnancy, 42 stated that they were sufficiently afraid of childbirth after instrumental or operative delivery to avoid a further pregnancy.

The two groups did not differ significantly in fear of subsequent childbirth. Women who had instrumental vaginal delivery were more likely than women who had cesarean delivery to attempt and succeed in vaginal birth in a subsequent pregnancy. Nevertheless, 94 percent of mothers who attempted vaginal birth following cesarean delivery were successful.

The authors conclude that fear of childbirth is common in women who have had instrumental or operative deliveries. This fear is sufficiently strong to cause a significant number of women to avoid further pregnancies. Of women who do have subsequent pregnancies, more women are likely to have a spontaneous vaginal birth delivery following an instrumental vaginal delivery than a cesarean delivery. However, the majority of women in both groups who attempt vaginal delivery in a subsequent pregnancy are successful. The authors call for increased efforts to achieve vaginal delivery in the first pregnancy, and for appropriate patient education and emotional counseling following instrumental or operative delivery to reduce negative concerns about childbirth.

editor’s note: I wonder how many more women feared subsequent childbirth but did not want to disclose their feelings to the investigators? Important questions to ask are: how frequently do women find the process of childbirth so unpleasant or frightening that they are unwilling to conceive again, and how do these emotions influence a woman’s relationship with her partner and her family? Besides great sadness that one of the most joyful experiences in life is instead a negative and distressing event, what other pathologies are created from the ramifications of an unpleasant childbirth experience? Family physicians have become aware of the need to screen for depression in new mothers. Perhaps we also should ask about the birth experience and be vigilant for a pervasive emotional pathology, especially in mothers who have operative or instrumental deliveries. The good news from this study is that such mothers are likely to achieve vaginal deliveries in subsequent pregnancies. However, we know little of the mother’s perspective of the experience. Childbirth is now a generally safe event; physicians and nurses should try to make the process as positive, emotionally and psychologically, as possible for everyone involved.—a.d.w.

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