What should the RCOG advise women about risk?

The Royal College of Obstetricians & Gynaecologists (RCOG) is to consider giving pregnant women advice about the relative risks of vaginal births and caesarean sections, according to the New Scientist.

The magazine reports that the RCOG has been prompted to look at the issue by a 2015 UK Supreme court ruling awarding damages for a baby who sustained brain damage during a vaginal delivery. The report continues:

“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.”

A decision by the RCOG to warn women of the risks of vaginal birth will be controversial, because vaginal birth is the default option – this is how babies are supposed to be born. When it goes well, a vaginal birth is much easier for a woman to recover from than a caesarean. It seems to be better for the baby too (though the evidence isn’t completely clear-cut).

But of course, not all vaginal births go well and, as the article states, the risks of injury to a woman’s pelvic floor muscles increase as she gets older. Many women are now having first babies in their 30s and 40s, making them more susceptible to injury than younger women. The article points out that older women are also more likely to need emergency caesareans, which carry higher risks than planned caesareans.

The big problem is that decisions to do with birth are not black-and-white: they’re all about assessing relative risk. Some older women have straightforward, uncomplicated vaginal births. Some younger women require emergency caesareans or have difficult forceps deliveries.

In an ideal world, health professionals would be able to assess factors such as a woman’s age, general health, pelvic size and position of baby and advise her of the most sensible course of action accordingly. Until someone collects and analyses the data, however, we can’t confidently predict what combination of risk factors mean that a woman will find it difficult to give birth vaginally.

When women talk about their experience of birth trauma, some report being coerced into having a caesarean (usually an emergency caesarean) when they wanted to continue trying for a vaginal birth, while others who wanted a caesarean have been forced against their will to attempt – or continue attempting – a vaginal delivery. Both are traumatic, and both can result in physical and mental health problems. The worry is that sometimes the advice given to women is driven not necessarily by what’s best for them and their baby but by targets, ideology or a desire to save money.

So where does this leave the RCOG? My view is that they should make women aware of the likely risks both of planned caesarean and of vaginal birth (and also that the risks of attempted vaginal birth include an emergency caesarean). Women should be allowed the opportunity to make decisions based on the best available evidence.

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