Following a UK Supreme Court ruling in 2015, doctors are considering offering pregnant women official advice on the risks of vaginal birth as well as caesarean sections

Consent form needed? Sputnik/Science Photo Library

FOR the first time, pregnant women in the UK may be given official advice about the relative risks of vaginal births and caesarean sections.

The move comes in the wake of a landmark 2015 UK Supreme Court case that awarded damages for a baby who sustained brain damage during vaginal birth. In this case, the plaintiff had a higher than usual risk of having a difficult birth, due to having a small pelvis and diabetes. But doctors didn’t inform her of these increased risks – an act of “medical paternalism”, said the presiding judge, who decided in the mother’s favour.

This ruling is seen as applying to all births. Although advice is available for those who seek it out, women are not officially warned about common risks such as tearing and incontinence, because vaginal birth is seen as the default outcome of pregnancy.


Rising risks

In many countries, including the UK, the average age of mothers at birth has been rising for decades. For example, in 1973, the average age at childbirth in England and Wales was 26 years, but by 2014 this had risen to 30. Research is now revealing how age raises the risks from vaginal delivery. A recent study by Hans Peter Dietz of Sydney Medical School, Australia, found that women who have their first child later in life are more likely to have major pelvic floor injuries during vaginal birth – damage that can lead to incontinence (American Journal of Obstetrics and Gynecology, doi.org/bkps).

For every extra year at age of first childbirth, he found that the risk of injury to a woman’s pelvic floor muscles from vaginal birth rises by 6 per cent. The risk of one of these muscles detaching from the pubic bone – which greatly raises the risk of uterus prolapse – was 10 per cent for a 20-year-old having a vaginal delivery without the use of instruments like forceps, but this doubled to 20 per cent for a 40-year-old.

Age is a factor because our muscles and ligaments get less stretchy as we grow older. This makes them more likely to tear during childbirth, and increases the likelihood of needing an emergency C-section, which carries a higher risk of infection, haemorrhage and blood clots than planned C-sections.

Dietz argues that women should be warned about how factors like age and having a big baby make vaginal birth more difficult. In April, he suggested that, given that patients are warned of risks as low as 1 in 1000 before surgery, it is incongruous not to warn a woman having her first child at 38 that she has a 15 per cent chance of an anal tear (American Journal of Obstetrics and Gynecology, doi.org/bkpw). “They have the right to know that,” he said.

“You should be able to weigh up the risks, but you can’t if you don’t have the information“

At the moment, women considering C-sections are warned about potential risks, like wound infections, blood loss and riskier future pregnancies. But women aren’t warned about the risk of bad tearing during vaginal birth, which can lead to problems in later life.

“They have got leaflets about C-sections, yet most people opt for a vaginal birth and there are no risk leaflets for them,” says Bryan Beattie, an obstetrician in the UK’s National Health Service.

Doctors are now considering a major change. The UK’s Royal College of Obstetricians & Gynaecologists will meet this month to discuss how patient information for many different medical procedures should be altered in light of the court case, and will start trialling them as soon as possible. They are considering issuing one on vaginal births, says the college president David Richmond. “It’s terribly sensitive and difficult,” he says.

Proponents of natural births predict that warnings about the risks of vaginal delivery may lead to more people choosing C-sections. The risks of vaginal births need to be balanced against the potential harms from C-sections, such as babies being born with breathing difficulties and risks to future pregnancies, says Louise Silverton of the Royal College of Midwives. “We need a healthy debate on what the emphasis should be.”

Some argue that leaflets won’t be enough, and that women planning a vaginal birth should sign a consent form that details the risks, just as with any medical procedure. However this is likely to meet with opposition from midwives and campaigners for more natural childbirth approaches. “A vaginal birth is not a treatment, it’s a natural consequence of being pregnant,” says Deborah Chippington Derrick of the Association for Improvements in the Maternity Services.

Beattie says ultimately only the woman herself can decide which risks are most important to her. “You might say to me: ‘I could cope with a wound infection if I had a C-section but I could not cope with faecal incontinence from a bad vaginal delivery’,” he says. “You should be allowed to make that choice but you can’t if you don’t have the information.”

This article appeared in print under the headline “Doctors may warn of birth risks”

Leader: “ Doctors should warn women about the real risks of childbirth ”