25% of women undergo caesarean sections in the UK.
A second stage caesarean section occurs when a caesarean section is performed at full dilation of the cervix and accounts for around 2% of all births. It is well known that this can cause complications, both for mother and baby. These complications are usually due to difficulties encountered trying to disengage the baby’s head, which by the time of delivery is deeply wedged inside the mother’s pelvis.
Attempts are often made to free the baby’s head by the attending obstetrician putting their hand between the baby’s skull and the mother’s pelvis, when there is a complete lack of space in which to do so. Furthermore, it is common for an assisting doctor to apply upward pressure to the baby’s head via the vagina. Both techniques place a huge amount of pressure on the baby’s skull and can result in skull fractures, inter-cranial haemorrhage and bleed on the brain or hypoxia (lack of oxygen), leading to brain injury. There is also a risk of damage to the mother’s uterus, potentially leading to complications in future pregnancies.
Over the last 10 years growing evidence has highlighted the risks involved in performing a caesarean section in the second stage.
Impacted foetal head injury case studies
Following an inquest into the death of Nixon Tonkin there was a case overview in 2014. Nixon had suffered significant head injuries including skull fractures and subdural and subarachnoid haemorrhages and brain swelling. Following a Coroner’s Inquest, the cause of death was most likely fractures occurred with 2 fingers pushing on the head via the vagina in an attempt to dis-impact the head from the pelvis during the caesarean section.
Following that inquest new procedures were introduced which meant that there had to be a consultant present during an anticipated impacted head C-section. The use of cupped hands or a foetal pillow and other techniques including reverse breach extraction should be used as a last resort or by an experienced clinician. The Coroner further recommended that there should be further training in simulated emergencies and attendance at national workshops and include training of midwives involved in those types of deliveries.
Zhang v Homerton
In the high profile case of Zhang –v- Homerton a negligent technique was identified in this particular case. Whilst freeing the head, the baby suffered sub-galeal haemorrhage, depressed fracture to right parietal bone and associated inter-cranial haemorrhage, resulting in substantial and permanent brain damage. The Judge in this case ruled in favour of the Claimant finding that the technique to dis-impact the foetal head with pushing from below was a negligent technique for dis-impacting the foetal head at a caesarean section.
There are currently no formal ‘best practice’ guidelines in place offering guidance to doctors on how best to deal with these deliveries. As a result, this is an area where claims against the NHS are increasing. It has been identified that there is a high risk of complications and it has been increasingly highlighted as a complex delivery, even in experienced hands.
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About the author
This article was produced for Brain Injury Group by Clare Milne, Partner and Head of Clinical Negligence at member law firm Girlings Solicitors. Girlings have one of the largest medical negligence departments in Kent, with offices in Canterbury, Ashford and Herne Bay.
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