medical negligence

Trust admits failure to properly advise woman on risks and benefits of vaginal delivery vs caesarean section

Most birth experiences are positive, with a safe outcome for mother and baby, but childbirth is not without risk and complications can occur.

In the antenatal period, women should receive full and unbiased evidence about the risks associated with Caesarean births, other interventions and vaginal births and should be empowered to choose the birthing option that they believe is the right birthing option for them and their baby. However, in practice, whilst the risks of Caesarean section are often discussed, the risks of a vaginal birth are not.  

Many women are entirely unaware that in the UK nearly 40% of women giving birth have an instrumental delivery or a caesarean section; that for first-time mothers, this rises to 50%; or that 4% of women suffer third or fourth degree tears during child-birth, which can lead to life-changing, long-term problems with bowel control and incontinence. 

Tees Law’s specialist Medical Negligence team supports more and more women, who, despite requesting a caesarean section or expressing concern about a vaginal delivery, have been counselled in such a way that steers them towards a vaginal delivery as the counselling frequently omits information on the risks of vaginal birth. 

Unfortunately, they have then gone on to endure a traumatic birth, with significant and often permanent chronic mental health and/or physical difficulties. In some cases, their babies may have suffered injury.

In 2018, Anna (not her real name) suffered a third-degree tear while giving birth vaginally. During her pregnancy she had raised concerns about vaginal delivery and had asked about a caesarean section on numerous occasions as she had pre-existing bowel difficulties (slow transit and severe constipation) which necessitated regular laxatives and irrigation. Sadly, erroneous and incomplete information provided throughout her antenatal care denied her the opportunity to exercise her right to make a fully informed choice for a Caesarean birth. Had she been appropriately supported and advised, she would have avoided the third-degree tear and its consequences, which include urgency and episodes of incontinence.

Pre-existing conditions

At her booking appointment, Anna informed the midwife of her pre-existing bowel condition and expressed her concerns regarding the impact that pregnancy and birth might have on this. Anna had been under the care of a bowel specialist, Professor Middleton (not his real name) for a number of years, who had previously mentioned that she might wish to consider a C-section. She also informed the midwife about her severe visual impairment (she was registered blind). The midwife booked Anna in for consultant-led care.

At the first meeting with the consultant obstetrician, Anna was advised to stop taking stimulant laxatives because of the risk they might trigger early labour. She asked about delivery by C-section, explaining her concerns about the effect childbirth could have on her bowels. She was simply told that vaginal birth was safest for the baby. She did not, however, receive any guidance on the risks or benefits of vaginal delivery, or how these compared to the risks and benefits of C-section, especially in relation to her specific concerns about her bowel health and the management of this.

Missed opportunities

The pregnancy progressed and Anna was referred to the 1-1 midwifery team as her sight loss was making it difficult for her to get to appointments. Anna had further conversations with the three 1-1 midwives, as well as another colleague of Professor Middleton. She was reassured that she could continue to take her medication, specifically the stimulant laxative bisacodyl and that vaginal delivery was best for her baby and was reassured that vaginal delivery would not affect her bowels.

Soon after, Anna found out that the baby was ‘back-to-back’, a position that increases the risk of complications during delivery. She was told not to worry and recommended some movements she could do to encourage the baby to rotate.  

When the baby was overdue, Anna asked again about the possibility of having a C-section. She was concerned about the size of the baby and whether she would be capable of giving birth vaginally. Once again, she was reassured about vaginal delivery. The risks of c-section were explained to her, including the very small risk of bowel injury from c-section. The risks of vaginal birth were not discussed. It was also explained that it would be hard to arrange a c-section at this late stage and she would not be a priority for a theatre slot.

An agonising delivery

When Anna began to have contractions, the midwife advised her to try to empty her bowels; her usual medication did not work, however, and she was unable to do so. Anna continued to have contractions for the next two days before she was finally told to attend the labour ward. At that point, her contractions slowed, and she began to sleep out of exhaustion. The midwife put Anna in various positions but to no avail.

Anna asked about having a C-section but was told it would now be too dangerous for the baby. A doctor was called, and Anna was taken to theatre. Desperate for the ordeal to be over and for her baby to be born, she signed a consent form, with the help of the midwife, that she could not read. She was not presented with any other options. Instead, the doctor attempted to deliver with ventouse and, when that did not work, using rotational forceps. No episiotomy, to reduce the risk of severe tearing, was performed.

After the baby was delivered instrumentally, Anna was informed that she had suffered a third-degree vaginal tear. She was then told that this could cause bowel problems by medical staff who were seemingly unaware that she already suffered from a bowel condition. During Anna’s recovery on the Advanced Care Unit, the doctors also seemed unaware of her pre-existing constipation. She was only given her usual laxative medication (bisacodyl) four days later after asking several times and she was told she could not use irrigation because it might damage her vaginal stitches.

Failure to inform of the risks

After returning home from the hospital, Anna continued to experience severe constipation. Professor Middleton advised her to take six macrogol in one hour, which was effective but led to a total loss of control. After that, she tried several different medications to varying degrees of success. She continues to have a problem with balancing medication the need to take laxatives and irrigate to address her pre-existing slow transit and constipation, with the need to manage the urgency and incontinence that the third degree tear has left her with. This is very restricting and time consuming, and the incontinence means that Anna has no option but to work from home. Managing her condition is even more challenging because of her sight loss.  She has experienced symptoms consistent with a diagnosis of PTSD, while also suffering stress and anxiety.

There were serious shortcomings in Anna’s maternal care. In antenatal appointments, she was not presented with information on the risks of vaginal delivery to allow her to make an informed decision. She later found out that the Consultant Obstetrician had not discussed all aspects of her bowel condition with Professor Middleton antenatally, despite being assured that everything had been considered. Anna specifically asked about a C-section in relation to bowel function on three separate occasions during pregnancy; each time she was told that a vaginal birth would be best for the baby and there was a small risk of bowel injury from C-section.

Fight for justice

Anna is one of many women who have suffered injury and long-term complications from a vaginal birth that should have been avoided. In the case where pre-existing conditions are not sufficiently taken into account when considering delivery options, the failures are even starker.

Official NICE guidelines state: “For women requesting a caesarean section, if after discussion and offer of support… a vaginal birth is still not an acceptable option [Trusts should] offer a planned caesarean section.” Yet a report by Birthrights in 2018 revealed that only 26% of Trusts offered C-sections in line with NICE best-practice guidance.

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