“Too posh to push” is an expression we have heard in the media over the last fifteen years, reflecting an apparent trend in society, particularly for celebrities, to opt for elective caesarean sections (C/sections) as part of their birthing plan.
However, for many mothers, the desire for a natural vaginal birth – in a public or private hospital setting – remains a priority. The attending obstetrician, in these circumstances, may nevertheless be faced with complications during labour that indicate the need for a c/section.
Two of the most common complications are Mum’s failure to progress during either the first or second stage of labour, or the potential for foetal distress. Other complications include significant antepartum (antepartum: before childbirth) or intrapartum (intrapartum: from the onset of labour through to delivery of the placenta) haemorrhage; life threatening sepsis (where the process to vaginal delivery would take too long to remove the source of infection); and the risk of a third or fourth degree tear. With the foetus, there is also the risk of shoulder dystocia – if there is lack of progress due to poor uterine contraction and the foetus is relatively large and in a position that increases the risk.
Failure to progress in labour is becoming more of an issue with increasing foetal macrosomia (large babies) (stemming in many cases from poorly controlled maternal diabetes), because large babies are more likely to get stuck during the birthing process. According to an Australian Institute of Health & Welfare Web Report on Australia’s Mothers and Babies (2022), other factors are maternal age (56% of mothers over 40 had c-sections in 2020) and maternal obesity (46%).
C/sections are categorised in the medical profession by urgency. C/sections in an unplanned emergency setting are either a Category 1 (immediate threat to the life of woman or foetus), Category 2 (maternal or foetal compromise which is not immediately life threatening) or Category 3 (no maternal or foetal compromise but needs early delivery).
The categorisation of C/sections assists obstetricians to take into account the time required for transfer to theatre, for appropriate anaesthesia and the planning required to have staff available for resuscitation of the baby, if required. This is particularly important outside of normal hospital hours.
Category 1 C/sections require delivery of the baby as rapidly as possible but because there is the potential for added problems due to the risks of performing any surgery rapidly, it is desirable to address developing complications at an earlier stage to avoid these types of emergency settings. Most intrapartum C/sections are category 2.
There is no firm obstetric guideline on the time it should take from a decision to perform a C/section to delivery, however, based on a 2012 Australian Health Review article (Safe timing for an urgent Caesarean Section: What is the evidence to guide policy?) and various clinical audits of large tertiary hospitals, the decision to delivery interval is likely to be accepted as reasonable in Australia if it is performed within 70 minutes. Delay resulting in injury to the baby may form the basis for a claim for compensation.
Monitoring of labour usually includes a partogram (a graphical representation of progress in labour, using information from vaginal examinations) and cardiography (a tracing which shows uterine activity, time and the fetal heart rate). If labour is being actively and appropriately managed, the partogram can inform as to when action – by way of C/section – should be discussed by the obstetrician with the mother. Similarly, CTG interpretation might suggest very abnormal changes and a high risk of hypoxia and acidosis in the fetus (high amounts of acid levels in the blood), requiring action.
Once it is determined that the baby might be acidotic, there is a need to deliver relatively quickly as it removes the potential for ongoing hypoxic insult to the baby. An obstetrician has to weigh up the potential risks of instrumental delivery versus C/section. They may also have to consider the risk of proceeding to C/section if Mum is fully dilated. A 2014 Journal of Obstetrics and Gynaecology article (S.L. Seal, A. Dey, S.C. Barman, Gourisankar Kamilya, J. Mukherji) suggests that C/section in these circumstances is both technically demanding and associated with increased intraoperative trauma.
It’s clear that the considerations for C/section are complex and, like all surgery, not without its own risks. Our firm has acted in many cases where the indications for c/section have been clear and unfortunately, have not been acted upon in a timely manner.
If you would like to speak to one of our experienced solicitors, please contact us on 02 4050 0330, or book an appointment online.
