Mr Lawrence Impey talks about "Birth Injury" in Claims Magazine (Issue 14)
Aug / 2014
Mr Impey shares his thoughts on caesarean section.
The caesarean section argument: random thoughts of an obstetrician
One of the most common allegations of negligence is that the obstetrician should have performed a caesarean section, or should have performed it earlier. It is exceedingly rare for them to be accused of negligence for performing a caesarean. Increasing numbers of babies are born by caesarean anyway. NICE has even produced guidance that under certain circumstances mothers may have a caesarean section for no medical indication. So why is caesarean section not simply recommended as the best way to have a baby? Is it not just safer?
Safety for the baby
The answer is complex. For how does one define safety- what outcome should we consider? A baby is more likely to have breathing difficulties if born by elective caesarean section. It may have different immune and stress responses. It is less likely to breastfeed and breastfeeding has important long term health benefits. The most important outcome, however, would be death or handicap, and a baby is probably less likely to die or be handicapped if it is born by caesarean section a week before the due date. This is logical: labour can cause serious problems and these are not always predictable or even preventable, even without negligence. So should this be the end of the story? In reality, the risks of labour are exceedingly small. For most babies that are handicapped, the insult originated long before labour- the last 12 or so hours of an 8 and half month journey. Indeed a ‘good’ labour is probably no more risky than a caesarean. And even the notion that caesarean section protects against death is debated: data from South America suggests that the reduction in deaths in labour is more than offset by an increase in deaths in the early neonatal period.
The real difficulty is that there are other people to consider. There is the mother’s safety, at this delivery, but also at future deliveries. There is also the safety of the next baby or babies. And then there is the safety of other people.
Safety for the mother
For the mother, the safest delivery is almost always a normal one. The least safe is a caesarean section in labour or at the end of labour. And somewhere in the middle, is an elective caesarean section, an operation where the most skilled people are available and it is not the middle of the night. So her safety is dependent partly on the chance of the labour ending in caesarean section: if she has, say, a 75% chance of this, then at the point of decision it is safer for her to have an elective caesarean section. Likewise, if the risk is 10%, it is safer to attempt the labour. Unfortunately, prediction is imprecise. Even more unfortunately obstetricians do lots of caesarean sections in labour. If a mother has a high chance of a long labour that ends in caesarean section anyway, it should come as no surprise that she might prefer to have the procedure done in a cool and planned manner at 9 o’clock on a Monday morning. With a high risk of caesarean section in labour, the argument that a caesarean section is less safe for the mother is difficult to make.
It is not, however, difficult to make when you consider the next pregnancy. This is where the real risks of caesarean section hide. The scar on the uterus is a weak point. Rupture in pregnancy of a normal scar can happen but is exceedingly rare: it happens in 0.5% of subsequent labours and this can be disastrous for mother or baby. Not only can it rupture, but it also seems to encourage the placenta to implant over it. The placenta then occasionally invades the scar, the uterus and even into adjacent organs such as the bladder. The risk increases considerably the more caesarean sections that a mother has. For the surgeon this is a bit of a headache; for the mother it can be fatal. Until delivery, the placenta is perfused by a huge volume of blood. When it separates after birth, this blood flow stops because the uterine muscle contracts and compresses the blood vessels formerly supplying the placenta. If the placenta is stuck, or more particularly partly stuck because it is in the scar, the vessels are not compressed by uterine contractions and the blood keeps coming onto the operating theatre floor. The whole uterus needs to come out very quickly and most mothers do not bleed to death. Admittedly, this scenario is still rare, but the incidence of this ‘placenta accreta’ is increasing dramatically.
The next baby is also at increased risk if an older sibling was born by caesarean. It is not certain that this increase is a direct result of the previous caesarean section, or of something else, but the risk of stillbirth, including before labour, is increased in women who have had one or more caesarean.
And finally there is the safety of other people.
What about precious NHS resources? It is more expensive to have caesarean. But it is not really about money. In 2000, a seminal research paper was published demonstrating a slight increase in safety, a decrease in death rates as well as morbidity, if babies that were upside down, or breech, were delivered by elective caesarean section. ‘Normal’ breech births rapidly all but disappeared in the West. But a few remained, either because the baby was not known to be breech until late labour, or because the mother wanted a natural birth. These babies are now at more risk because obstetricians see so few breech births they often do not have the necessary skills. Could normal birth go the same way? Labour will still always happen, either because of choice, or because its starts early, earlier than when a planned caesarean would occur.
We need to address the much bigger contribution to death or handicap that is made by the rest of pregnancy. Labour is here to stay and will not be completely replaced by caesarean section: the human being was not created with a zip on the abdomen. Obstetricians need to understand better why some babies run into difficulty in labour. They need to get better at predicting, preventing and treating this. This often requires caesarean section. But as is so often the case, as we try to prevent one problem, we create a whole new set.
Mr Impey says “Getting the right obstetric expert is crucial in birth & pregnancy claims”.
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Mr Lawrence Impey
BA FRCOG, Consultant in Obstetrics and Fetal Medicine, John Radcliffe Hospital, Oxford
Lead clinician for the John Radcliffe Fetal Medicine Unit for high risk babies & Silver Star Unit for complex maternal problems