DELIVERY OPTIONS
Cesarian Birth
Operative Vaginal Delivery

SUMMARY: After a poor obstetric outcome, disappointment about method of birthing may become a central malpractice issue.There is some justification for clients' beliefs that obstetricians have more discretionary choice than patients over mode of delivery.When there was a choice between cesarian and operative vaginal delivery, there may not have been adequate disclosure of relative risks to the mother.

Mode of childbirth - normal, forceps, vacuum extraction, cesarian - is a common Cause of medical malpractice Action following adverse outcome for mother or infant.

After a poor obstetric outcome, disappointment about method of birthing may become a central malpractice issue.

The contention is that, without the benefit of hindsight, the obstetrician should have known that the outcome would have been better with a normal delivery or, conversely, earlier cesarian section.

Each delivery method has its own advantages and disadvantages, and at times the obstetrician must weigh the perceived risks to the mother against those to the infant.

In most circumstances, cesarian delivery benefits infant more than mother, though, if the fetus is particularly large, cesarian risks are lesser for the mother also.

Cesarian Birth

The major distinction is between vaginal and cesarian birth.

Cesarian rates (numbers of cesarians per hundred total births), after steadily rising during preceding decades, have been falling modestly for more than a decade⁽¹⁾.

There is some justification for clients' beliefs that obstetricians have more discretionary choice than patients over mode of delivery.

There are, nevertheless, relatively large variations in rate between countries and, within any given developed country, between regions.

In the US, for example, cesarian rates for different States range from 11% and 27%.

Even within any one hospital, obstetricians with similar practices may have markedly different cesarian rates. Currently, obstetricians with lower rates tend to be younger, domestically-trained, in group practice and undertaking smaller numbers of deliveries annually⁽²⁾.

Often the client has had a previous cesarian delivery for reasons that do not apply in the present pregnancy or labour. In these circumstances, the previous enthusiasm for attempting vaginal birth (Trial Of Labour) is being re-evaluated because occasional catastrophic outcome is difficult to predict.

Medical malpractice litigators should be aware that aggressive pursuit of a policy of Vaginal Birth After Cesarian (VBAC) results in a significant increase in rupture of the uterus and neurologically-damaged infants⁽³⁾.

Some common indications for cesarian delivery are universally accepted⁽⁴⁾, though interpretation of the indication in the individual case may be contentious:

CPD refers to a tight fit between the fetal head and the mother's bony pelvis. Premature separation (abruptio) of the placenta from the wall of the uterus is commonly an obstetric emergency. The degree of placenta previa (location abnormally low in the uterus) determines whether cesarian section is required.

In considering Cause of Action, litigators should be aware that some indications for cesarian delivery are controversial:

Operative Vaginal Delivery

Operative vaginal delivery means birth assistance by obstetric forceps or vacuum extractor.

In most developed countries, the previous rise in cesarian rates accompanied falls in rates of operative vaginal delivery⁽⁵⁾. Canada has traditionally had one of the highest operative vaginal delivery rates at around 16% of total births.

When there was a choice between cesarian and operative vaginal delivery, there may not have been adequate disclosure of relative risks to the mother.

Various women's groups have had significant influence in subsequently reducing cesarian rates, and individual patients may weigh this aspect of care in choosing an obstetrician.

By contrast, some obstetricians, female more often than male, will persist with, and insist on, normal vaginal delivery beyond what conventional obstetric practice considers safe.

Paradoxically, a survey⁽⁶⁾ found that 17% of female obstetricians practising in London, England, would prefer cesarian delivery for their own normal pregnancies.

88% of these physicians cited fear of damage to the perineum (skin and underlying tissue between vagina and anus) as the main reason for their personal choice.

The immediate complications of perineal injury include pain, infection, and hemorrhage.

Long-term adverse effects include pain during intercourse (dyspareunia), cosmetic deformity, and incontinence of flatus or feces.

The current indications⁽⁷⁾ for forceps delivery according to the Society of Obstetricians and Gynaecologists of Canada (SOGC) are as follows:

However, male obstetric residents deliver by forceps significantly more often than do female obstetric residents⁽⁸⁾.

This gender difference holds true for both vaginal and total deliveries.

We have previously reported the little-publicised high frequency of injury to bowel, bladder and nerves following uncomplicated normal delivery.

Unrecognised injury to the anal sphincter (valve) is common after vaginal delivery, particularly forceps, and is frequently accompanied by disturbed bowel function⁽⁹⁾.

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