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The importance of informed choice for mothers in considering options for giving birth

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    In this second blog in a series relating to injuries suffered around the time of birth, we will be looking at the need for parents to be given full advice as to the benefits and risks of different options for delivery, and the implications of a recent significant legal case.

    By Kerstin Kubiak

There are many clinical reasons why a mother should be advised that she either a) should have a caesarean section or b) should be made aware of the risks of natural birth against caesarean so that she can make an informed choice of her options and give consent accordingly.

Ask any expectant mother what their first hope for their unborn child is and almost all will say for them to be delivered safely and to be healthy; most mothers will put the well being of their child above anything else, including their own health. This is of critical importance in assessing the information a woman has the right to know and consider when there are risk factors in undertaking a vaginal delivery.

In a recent landmark case [1[ the Courts have ruled that a patient has the right to know of ALL relevant material risks so that they can make an informed decision in giving consent to medical treatment or care, even if the doctor themselves wouldn’t consider those risks to be significant.

The development of case law:

The previous law as to the information required for patients was what the reasonable doctor would consider appropriate in advising their patients of risks.

The law has now developed so that the Supreme Court has ruled: “The test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk, or the doctor is or should reasonably be aware that the particular patient would be likely to attach significance to it.”

In the Scottish case of Montgomery the mother suffered a complication of shoulder dystocia during the birth of her child.  Shoulder dystocia is where the baby’s shoulder becomes impacted against the mother’s pubic bone obstructing delivery. Sadly, the baby was stuck for 12 minutes and suffered an acute deprivation of oxygen during this time as the umbilical cord was compressed. This caused a severe brain injury and cerebral palsy.

Mrs Montgomery sued the hospital because she had expressed concern during her pregnancy about whether she would be able to deliver her baby vaginally because she was diabetic, of small stature and was carrying a large baby.  Although she carried a 9-10% risk of shoulder dystocia as a result, she was not advised of this nor given the option to consider delivery by way of caesarean section. She stated that had she known of this risk she would have sought to undergo a caesarean section, thereby removing the risk of serious injury to her child.

How this applies to maternal choice:

From now on mothers need to be fully informed of the option of proceeding with caesarean section where there are potential complications in vaginal delivery. Some examples of risks which may lead to potential complications during childbirth:

  • Where there is an increased risk of shoulder dystocia;
  • Where is there is a history of complications with previous deliveries;
  • The baby is in a poor position for delivery, e.g. breech or transverse;
  • You have the condition of placenta praevia, where the placental obstructs the cervical opening;
  • Where there is a multiple pregnancy, i.e. twins or triplets;
  • Where the baby is abnormally small or large;
  • You have been diagnosed with pre-eclampsia or hypertension (high blood pressure);
  • You have an underlying condition, such as heart disease;
  • You have a viral infection such as herpes or HIV.

It is then for the mother to determine the importance of any risks and to discuss all options with her midwife and consultant and make an informed choice. In my experience most mothers opt for the safest option for their child or if electing vaginal delivery chose to do so in a hospital environment where they can have an emergency caesarean very quickly if needed.

The overriding factor of importance is ensuring that parents are given information to enable them to make a choice which is well informed and considered.  If no such discussion takes place and complications do occur during childbirth which cause injury to the mother or baby then this may lead to a clinical negligence claim.

In our next blog in the series we will be looking intra-uterine growth restriction, where a baby’s growth can become restricted during pregnancy, and the importance of diagnosis and management during pregnancy.

[1] Montgomery v Lanarkshire Health Board [2015] UKSC 11

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