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Caesarean sections: a woman’s choice?

Posted: 14/05/2021

Childbirth should be a very rewarding experience, although choosing the method of delivery is not always a straightforward decision. There are a number of factors to be considered, both medically and emotionally, when making a decision on how to deliver a baby.

What is a caesarean section and when is it necessary?

A caesarean section, or C-section, is a surgical operation whereby an incision is made into a mother’s abdomen and womb to deliver a baby and is usually performed under spinal or epidural anaesthetic. Around 25% to 30% of women in the UK have a caesarean birth either out of choice or out of necessity.

Historically, the medical profession considered vaginal birth to be the safest means of delivery for both mother and child; however, there has been increasing concern over the safety of vaginal births where certain risk factors are identified. The position in the UK currently is that a caesarean section can be performed either as elective surgery, meaning that the mother has chosen this method of delivery, or because a consultant has decided that vaginal birth would be too dangerous for the mother or child.

Examples of when a caesarean section might be considered a medical necessity include where there is evidence that the mother is suffering from an infection or pregnancy-related high blood pressure (known as pre-eclampsia), or if there are concerns regarding a baby’s health, such as low blood pressure or oxygen levels.

Are there alternatives to a caesarean?

Should complications arise, those treating the mother may opt for an assisted or ‘instrumental’ delivery, where delivery of the baby is assisted with the use of an instrument such as forceps or a ventouse suction cup. Forceps are large, tong-like instruments which secure around the baby’s head and help to manually guide the baby out of the birth canal. Ventouse suction cups are securely fixed to the baby’s head and, during contractions, clinicians gently pull to help deliver the baby.

Assisted delivery is performed in about one in eight births in the UK and may be necessary if the mother has underlying health conditions that make pushing riskier, or if the baby appears to be tiring or in distress. As with any mode of delivery, certain risks arise with instrumental delivery (such as lacerations to the baby’s head from forceps) though complications are usually rare. If able to do so, clinicians should discuss the risks and benefits associated with instrumental delivery with the mother before agreeing a course of action. The final decision regarding the mode of delivery usually remains with the mother, unless she is incapable of making that decision.

Elective vs emergency – what is the position?

If doctors feel that a caesarean section is necessary they should, if possible, discuss the benefits and risks of a caesarean compared with a vaginal birth with the mother before proceeding. Factors such as a higher BMI and maternal age may be issues to consider when deciding whether to proceed with a caesarean section. The mother’s circumstances, concerns, priorities and plans for future pregnancies should also be taken into account. Some of the increased risks associated with caesarean births compared to vaginal births can include a lengthier stay in hospital, surgical complications, uterine rupture and an elevated risk of infant mortality. However, caesarean sections carry lower risks compared to vaginal births of postpartum urinary incontinence, faecal incontinence, vaginal tears and abdominal pain during birth and shortly after.

Complications arising from vaginal births sadly do occur. Some of the clients that the Penningtons Manches Cooper clinical negligence team advises have suffered injuries such as bladder prolapse, episiotomy infections and ongoing pain and disability. To attempt to mitigate the risk of injuries such as these, every expectant mother ought to be given the opportunity to consider her own health and wellbeing, along with that of her child, when deciding on the method of birth.

Choice and patient autonomy

Some women may choose to opt for a caesarean section for reasons both medical and otherwise. According to NICE guidelines, pregnant women should be offered information, advice and support to enable them to make informed decisions about childbirth. The woman's preferences and concerns are central to the decision-making process, and consideration should be given to specific risks which the mother feels carry particular significance for her. The final decision for mode of birth should be agreed between the mother and her obstetrician before the expected or planned delivery date.

The clinical negligence team is aware of an increasing number of cases where women request a caesarean section but are denied the opportunity to give birth in such a manner. In some cases, this has led to devastating consequences for mother and baby. Unfortunately, many women still feel that they are not being listened to when discussions are held around mode of birth.

The 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.’ However, statistics show that 15% of trusts have policies which do not support maternal requests for a caesarean section, 47% of trusts have inconsistent policies and only 26% of trusts offer caesarean sections in line with the NICE guidelines.

Choice is an important word when it comes to any medical procedure and patient autonomy is increasing in many areas of healthcare. Childbirth can be a magical and unforgettable experience and a woman’s autonomy in this situation must be protected as far as possible.

This article has been co-written with Georgina Wade, a trainee solicitor in the clinical negligence and personal injury team.

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