You are in: Home Page | Accident Types | Clinical Negligence | Clinical Negligence Articles | What is the best way to give birth?

What is the best way to give birth?

Introduction

New guidelines published by the National Institute for Health & Clinical Excellence (NICE) for the care of women during labour and childbirth published in September 2007 (Intra partum care - NICE Clinical Guideline 55) have led to a huge round of media articles and programmes on the subject.

The Guidelines have prompted speculation that NICE is actively promoting natural childbirth, homebirth, reduction in pain relief available and steps to reduce the availability of caesarean section. Much of the commentary suggests the motive is cost cutting for the NHS but the Executive lead for the intrapartum care guideline and deputy chief executive of NICE was adamant that the NHS needs to reduce caesarean sections because they carry significant risks for mothers and babies (also see WHO research carried out by Oxford University published by BMJ online 01/11/2007.)

The advice comes amid a national shortage of up to 10,000 midwives and with the news that the NHS spends more than £80million per year on caesarean sections.

Background

Those at NICE on the guideline committee have denied the guidelines are designed to save the NHS money by reducing unnecessary and costly medical interventions. They insist the guidelines are produced to underpin the principle that women should be provided with appropriate information and advice so that they can have a positive birth experience which is important for the wellbeing of both mother and baby.

Facts about birth in the UK

Homebirths

Only 2% of deliveries in England currently take place at home. NICE say all women should be given the option of giving birth in a midwife-led centre, hospital or home. NICE believe the number of homebirths could be increased to 30%. The National Childbirth Trust estimate 60% of women can safely give birth at home. The Royal College of Midwives insist homebirths are safe in the majority of circumstances. “There is some evidence to show that for very low risk women, homebirth may be safer than a hospital birth”, a spokesman said. The likelihood of medical intervention is reduced.

However a former Vice President of the Royal College of Obstetricians & Gynaecologists said it was “very doubtful” that the proposal to offer the guaranteed choice of birth at home with an NHS midwife by the end of 2009 could be achieved due to the midwifery shortage. Homebirths require two midwives to be present and it was hard enough to achieve one to one care in hospitals. Further, many obstetric doctors are doubtful that women would be fully informed of the risks. A spokesperson said “complications during childbirth are unpredictable and can occur even in low risk births”.

Caesarean sections

The World Health Organisation says the UK has one of the highest rates of caesarean sections in the world being 23.5% in England and 26.2% in Wales. 1 in 10 are ‘planned’ as opposed to emergencies. The rise in planned caesarean sections has been blamed on women being scared of pain or ‘too posh to push’. But in fact many happen because of problems picked up in pregnancies. Few NHS hospitals in England and Wales allow planned caesarean sections unless there is a medical reason to justify it. The NICE guidelines are clear about the advantages and disadvantages of caesarean section and when planned (elective) procedures should be offered as an option.

Legal Claims

Two of the most frequently occurring maternal birth injury claims we see at Thompsons involve those for:-

1) uterine rupture which can be a complication of caesarean section and

2) failing to diagnose and adequately repair pelvic floor damage. This damage can be avoided with caesarean section delivery.

1) Uterine rupture

New research has shown women are 50 times more likely to suffer a ruptured womb during childbirth if they have previously delivered by caesarean section. If the womb tears it is life threatening for both mother and baby. About 1 in 20 babies die as a result. Older mother and obese women are more at risk. The scientists found the condition affected nine in every 1000 mothers who tried to give birth to their second baby naturally after having a caesarean section for the delivery of their first. Research emphasised extra care should be given to women with a history of caesarean births and doctors should ensure these women are aware of all their birth options.

Thompsons obtained compensation for a mother who was encouraged to attempt a natural delivery when previously she required an emergency caesarean section for her first child. Regrettably the attending doctor allowed the client to push in the second stage of labour for longer than was safe. She suffered a uterine rupture which resulted in the need for an emergency hysterectomy. Fortunately her baby was delivered safely, but she had a much longer recovery period and her return to work was delayed. She suffered significant psychological damage as a result of being unable to have more children as she had planned. Thompsons secured for her £65,000.00 in compensation.

2) Damage resulting in incontinence

The reported incidence of third degree of perineal tears range from 0.6% to 2.3% and it seems likely the condition is under-reported. Unrecognised mechanical disruption of the anal sphincter is a major contributor to the subsequent development of anal incontinence. Between 26%-35% of women undergoing their first vaginal delivery develop an unrecognised sphincter injury.

NICE guidelines are clear that any woman with a perineal injury should be examined carefully in the immediate post delivery period to ascertain the extent of the injury. If there is any suspicion of a third or fourth degree tear or uncertainty as to the extent of damage they must be examined by an obstetrician fully trained in the recognition of third degree tears to detect an injury.

Failure to recognise a significant sphincter injury is the principle cause for successful claims in this area. Obstetric doctors writing in the British Medical Journal on the issue stated “until [this] injury is more fully understood and researched it is likely that the increased rate of caesarean section will continue and as recently suggested, it may be difficult to decline a patient’s request for caesarean section to avoid pelvic floor damage during childbirth on the basis of the current evidence”.

Thompsons have pursued many successful claims on behalf of women who have suffered significant pelvic floor injury which went undetected in the immediate post birth period. This resulted for them in appalling incontinence problems and the need to undergo secondary substantial repair surgery which, because they are ‘late’ repairs result in reduced prospects of success.

For more information about injuries sustained by mothers, babies or both, or on any clinical negligence issue please contact the Clinical Negligence Team at Thompsons.