Medicolegal issues in a second stage Caesarean Section

Second Stage Caesarean Section

Second Stage Caesarean Section (CS) occurs in around 2% of all births and recent data suggests that it is on the rise(1). There is irrefutable evidence that CS carried out at or near full dilation of the cervix leads to higher complications for the mother and her baby(2). All these complications are due to various degrees of difficulty encountered in the delivery of the engaged fetal head.

An assistant pushing from below is the most commonly used technique when difficulty is encountered during delivery at a CS. Other methods are described but these are difficult to perform and teach, often leading to other complications.

Medicolegal Case  
(Yiqun Zhang vs Homerton Hospital)

 This case was reported as an abstract at the RCOG congress titled:
‘Negligent technique for dis-impacting the fetal head at Caesarean Section’ 

A specialist obstetric registrar performed a caesarean section at almost full cervical dilation. During the operation, it was apparent that the baby's head had become deeply impacted in the maternal pelvic outlet. In the course of freeing it, the baby suffered trauma; a subgaleal haemorrhage, a depressed fracture to the right parietal bone and associated intra-cranial haemorrhage. These injuries led to substantial and permanent brain damage.
 
During the high court ruling the judge ruled in favour of the claimant and concluded:
 “I have considered the evidence very carefully…..I am satisfied both that the registrar attempted to rotate the Claimant's head, and deliberately and discretely moved the baby's head to the (mother's) right to enable her to insinuate her hand to flex and disimpact the head. The Defendant concedes – but, in any event, I would readily find – that each of those manoeuvres was inappropriate, dangerous, negligent and hence in breach of duty.”
 
The family's lawyers and the hospital trust have now agreed a settlement of over £3 million plus extra payments rising to £225,000 a year to pay for care for the rest of his life(3).

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Prof Steer has recently reported in the BJOG his experience of reviewing 4 cases in the last 3 years of perinatal deaths associated with skull fractures during delivery at CS (none of them with previous attempts at an instrumental delivery).  A common feature in all the cases was repeated attempts at delivering an impacted head at CS by the obstetricians. There was also upward pressure from an assistant’s hand inserted vaginally in all these cases. He concludes these cases suggest that it may be best to avoid further compressing an impacted fetal head by pushing a hand past it while also applying force from below.​

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Author's Conclusions

I believe that there are three main causes of the damage to a baby under these circumstances:

• Attempts by the obstetrician to introduce their hand between the fetal skull and maternal pelvis when there is a severe lack of space.
• Pushing by an assistant from below. Anyone who has attempted to push from below knows that the space is restricted and the angle of pushing makes it very difficult to judge the force required, moreover this force is applied to a small area of the skull when pushing manually .
• There can also be a significant delay in delivery of fetus after the uterine incision has been made in such cases (there is evidence that there is much higher risk of admission to NICU if the uterine incision to delivery interval is longer than 3 minutes)​(4). 

 
It is now estimated, that the skull fractures during a CS is amongst the top 3 causes of obstetric litigation.  For obvious reasons, most of these cases only get reported in the local press rather than medical journals and hence are not available to obstetricians. Links to some articles I have found are available here.
 
Most of these reports are of fetal death, there is no data to ascertain the number of brain damaged babies caused by the difficult delivery of fetal head but this number is likely to be significant.  I estimate that one traumatic fetal death occurs in every 500 second stage CSs. The incidence of HIE is likely to be more than this.
 
The difficult delivery of the fetal head therefore, is a very serious problem that seems to be getting more common. The effectiveness of all the techniques described in the literature is being questioned and their use can often lead to the very complications that we are trying to prevent. 

I also believe that the degree of difficulty encountered during the delivery of the head is not always possible to predict but is most likely to occur in advanced labour with a deeply engaged head or when an attempt at an instrumental delivery has been made. The cases discussed raise questions about the techniques that were used. A simple solution available to us is Fetal Pillow, an easy to use and effective device. The use of this device has been increasing since the recent publication of a RCT, Australia study and a case controlled study and provides a safer alternative to relying on manual techniques. Find out more here.
​

Author

Dr R Varma 
FRCOG
Consultant Obstetrician & Gynaecologist
r.varma@fetalpillow.com
 
About the author
 
Dr Varma is a consultant Obstetrician & Gynaecologist with 35 years’ experience in the field of O&G.  He is the inventor of fetal pillow and a part time Medical Director of Safe Obstetric Systems. He is still in active clinical practice in the field of Urogynaecology.

References

1. ​Unterscheider J, McMenamin M, Cullinane F. Rising rates of caesarean deliveries at full cervical dilatation: a concerning trend. Eur J Obstet Gynaecol Reprod Biol 2011;157:1414. 
2. Pergialiotis V, Vlachos, D G, Rodolakis A, Haidopoulos D, Thomakos N, Vlachos G D., First versus second stage C/S maternal and neonatal morbidity: a systematic review and meta-analysis, European Journal of Obstetrics & Gynecology and Reproductive Biology 175 (2014) 1524
3. http://www.itv.com/news/london/update/2013-10-01/multi-million-pound-payout-for-boy-brain-damaged-at-london-hospital
4. ​Danylyshyn-Adams K, Young E, Crnosija N. Time from Uterine incision to delivery in cesarean deliveries and associated neonatal outcomes.  Proceedings of American College of Obstetricians & Gynaecology annual conference (221)  May 2016.