Necessary or Unnecessary cesarean - only hindsight makes the safest judgement call

My focus in these blogs is usually in relation to non-medical cesarean deliveries, and the legitimacy of informed, educated women making the decision to choose this birth plan. However, there seems to be so much negative reporting recently on the subject of unnecessary cesareans that I wanted to wanted to post my thoughts.

Firstly, I sympathize with the many angry and disappointed women for whom their preferred birth plan of vaginal delivery did not result in a vaginal delivery outcome. Unwanted cesareans are undoubtedly more difficult to recover from (at the very least from a psychological perspective) than wanted cesareans. I am also open to the possibility that there are cases of unwanted cesarean deliveries where - had early prophylactic surgery not occurred - the vaginal birth plan may well have had the outcome of a vaginal delivery without injury to the baby or mother.

But the question is - at what point precisely does an unnecessary cesarean become a necessary one? Listed below are examples of litigation cases (2008 updates to be added) in which it was concluded that a cesarean delivery should have been carried out/ sooner.

*06 Sep 07 Jury Awards Parent $13.5M In Malpractice Case ...Gardner's pregnancy was allowed to continue for 42 weeks, two weeks past her due date. Gardner and her lawyers claimed that when Nathaniel was born in 2002, the doctor failed to monitor him during the cesarean section procedure. They said Nathaniel was deprived of oxygen for up to 25 minutes, resulting in cerebral palsy... Broadlawns attorney David Brown said they will challenge the $13 million verdict.
*01 Sep 07 Doctor found guilty of misconduct A doctor has been found guilty of misconduct for trying to force a baby's delivery 12 times, as the mother begged for a caesarean. The baby boy died as Dr Avanti Patil delayed the operation and battled with forceps and suction cups. The young mother, known only as Miss A, had been in labour for 24 hours at Southend Hospital.
*31 Jul 07 MEC to pay after baby's death Gauteng MEC for Health Brian Hlongwa has agreed to pay R103 488 in damages to a Johannesburg couple who claimed their first child, a baby boy, died in his mother's womb while she was waiting for a caesarean section to be performed.
*25 Jul 07 Payout victory at last for boy A 10-year-old boy will be paid compensation running into millions of pounds after Swansea health bosses lost the right to appeal the claim. Jac Richards, who was left paralysed following a 10-minute delay in his caesarean delivery...
*18 Jul 07 Boy,14, £2.6m for injuries suffered at birth A 14-year-old boy left facing a lifetime of catastrophic disability by injuries suffered during his birth has won a £2.6m compensation deal at London's High Court. Callum Halliday, of Hunter's Chase, South Godstone, was born by caesarean section at East Surrey Hospital, Redhill, in May 1993. But oxygen starvation has left him a victim of quadriplegic cerebral palsy, confined to a wheelchair and totally dependent on others for all his care needs. His legal team argued that, had it not been for a negligent delay in his delivery, Callum would have escaped serious injury.
*06 Jul 07 Team 4: Family Awarded $23M In Malpractice Settlement ...The lawsuit said a fetal heart rate monitor showed significant abnormalities from the time Jordan was admitted to the hospital. Despite the problems, doctors allowed her to continue laboring for eight hours. Grady was delivered by cesarean section, limp and pale, with no heart rate... Grady suffers from cerebral palsy.
*30 Jun 07 Lifelong care girl sues hospital trust ...Writ: failed at 23.30 hours to proceed to emergency caesarean section... it should already have been clear that a caesarean operation was urgently needed.
*15 Jun 07 Minister sued for R5m Alleged: ignored nursing staff's requests to perform a caesarian section. The doctors and the minister have denied allegations of negligence. The case has not yet gone to court.
*11 Jun 07 Hospital accused in baby death Alleged: refused to call a doctor, agree to a caesarean delivery, administer painkillers or even a give her a glass of water... The inquest continues.
*08 Jun 07 Birth tragedy - mum ‘ignored' ...Her mother told an inquest she had not been offered a caesarian, which she would have agreed to.
*05 Jun 07 Woman in post-delivery stroke sues CHC, doctor Alleged: failing to recommend or perform a caesarian section...
*02 Jun 07 Air Force must pay $24.5M in baby delivery case ...eventually called in and performed surgery, finding the baby half extruded from Evelyn Tremain's uterus and into her abdominal cavity.
*13 Mar 07 Compensation for Caesarean delay A 10-year-old boy left disabled after a delay in his caesarean delivery has won the right to receive compensation. Jac Richards suffered oxygen starvation before his birth at Swansea's Singleton Hospital, causing brain damage. London's High Court ruled he would have escaped injury had he been delivered 10 minutes earlier, and guaranteed Jac, from Llanelli, full compensation.
*28 Feb 07 NHS Trust to pay out over birth error A Seaford mother whose child suffered devastating brain damage after the hospital refused to deliver him by caesarean is to receive massive compensation.
*27 Feb 07 Hospital sorry for blunder at birth A family whose baby suffered brain damage when doctors refused to deliver him by caesarean section is set to be paid millions of pounds in compensation. Alison Jones, 46, had asked for the caesarean for the birth of her fourth child, Ellis, after complications during her previous pregnancies. She feared a scar on her uterus could rupture and put the baby at risk. Hospital staff played down her worries and induced labour but the scar burst and Ellis received devastating brain injuries.
*19 Feb 07 £6.6m for boy, 15 injured at birth ...Ryan was starved of oxygen towards the end of his mother's labour, but the signs were not heeded and his delivery delayed. By the time he was born by emergency caesarean section, he had already suffered brain damage.
*08 Feb 07 'I'd rather have nothing and my baby boy back' Parents of a baby that died just days after being born have been given £32,000 in compensation... The tot was starved of oxygen and suffered 99% brain damage during his birth... A problem with his heartbeat had been spotted during labour - however, it was not acted upon and the baby was delivered normally about 3 hours later. The hospital has now admitted, though, that had it acted earlier - such as carrying out a Caesarian section - Jake would probably not have been brain damaged and died as a result.
*24 Jan 07 Illinois Medical Negligence Attorneys Represent Birth Injury Claim [Judge]: approved the $9,500,000 settlement of a medical negligence case... [doctors] failed to recognize the significance of changes in the fetal heart rate as evidenced on the fetal monitor strips... [The baby] was delivered by emergency caesarean section on October 24, 2001... she was diagnosed with severe cerebral palsy, spastic quadriplegia, and seizure disorder.
*13 Jan 07 Mother, child awarded $1.8 million for injuries during childbirth Virginia Beach: A child and his mother were awarded $1.8m... The lawsuit alleged that Uy failed to order a sonogram at 38 weeks of the pregnancy, failed to deliver the child by cesarean, failed to manage the mother's behavior during delivery, and failed to properly manage a problem during delivery. A problem with the shoulder obstructed Twan Johnson's birth and resulted in Uy gripping the baby's head and pulling during delivery. Defense attorney Dante Filetti said Friday that the case came down to the amount of force used by Uy during the birth.
*22 Dec 06 Couple sues doctor over baby's delivery Morgantown: A Kanawha County couple says their doctor caused injury during the birth of their child by using forceps... Complaint says: ‘As a direct result of the forceps, Plaintiff Stacy suffered permanent injuries requiring surgery which relieved but did not eliminate her injuries.'... No judge has been assigned the case yet.
*28 Nov 06 Brain-damaged girl to get £4million pay-out A girl left brain damaged after being starved of oxygen in the womb today won a compensation deal worth more than £4m and an apology from the NHS Trust who managed her birth. The Chesterfield girl, now aged 12... suffered hypoxia during her delivery at Chesterfield Royal Hospital in November 1994, and has been left with devastating cerebral palsy as a result. Through her parents, she sued Chesterfield and North Derbyshire Royal Hospital NHS Trust, claiming she should have been delivered by emergency CS and that staff negligently failed to heed warning signs that her position in the womb was irregular. The trust denied responsibility but, at London's High Court, agreed to pay damages on the basis of 96% of a full valuation of her claim.
*23 Nov 06 Why did my baby die A nurse claims a refusal by doctors to give her a cesarean in time lead to the death of her baby... She urged medical staff to give her a cesarean explaining her first child had been delivered that way because of complications. But doctors refused, told her to go home and wait for contractions. Two days... unable to feel the baby moving. She returned to the hospital and her baby girl was delivered by emergency cesarean... The child was put into a ventilator but died 2 days later.
*23 Nov 06 Why did my baby die Recent malpractice suit yielded $8m settlement: The child now lives with an intractable seizure disorder - seizures that cannot be controlled with medication... The hospital resident tasked with measuring the fetal heart rate encountered the baby's face in the birth canal. This revealed that a cesarean was indicated, as opposed to a vaginal birth. However, when she relayed this information to the attending physician, he summarily dismissed it, insisting upon delivering the baby ‘naturally.' As a result, the baby suffered facial abrasions due to his facial skin being stretched excessively while being forced down the birth canal face-first. Upon his delivery, it also became obvious that his neurological status was compromised by both the blunt force trauma of the delivery and the deprivation of oxygen.
*10 Nov 06 Couple speak of heartache During the labour hospital staff failed to act on signs of distress on a trace of Lucy's heart rate shortly after 5pm and, instead of arranging for Mrs Walker to undergo a cesarean as was appropriate, encouraged her to go to the hospital canteen... [The NHS Trust] has agreed to settle the claim out of court.
*02 Nov 06 Windsor boy, injured at birth, wins millions Hartford Superior Court jury: awarded a medical malpractice verdict of almost $2.6m to a 4-year-old Windsor boy who has permanent limitations on the use of his right arm due to injuries he suffered as he was born, according to the boy's lawyer. [In addition,] the jury awarded $108,000 to his mother... for the emotional distress she suffered... the lawsuit alleged that Anastasi made 2 mistakes during the April 2002 delivery: *He pulled on Omar's head about 6 times with a vacuum extractor. *Once Omar's head had emerged, his shoulders got stuck in the birth canal... [he] put his hand on Omar's cheekbone and pushed his head sideways in an effort to dislodge him - but used too much force... the jury found Anastasi negligent in his use of the vacuum extractor but didn't find unanimously that he should have performed a cesarean.
*15 Oct 06 Baby death mum to sue hospital Ms Rees: believes the hospital delayed the delivery and treatment of her son... ‘I was considered high-risk because of my age from the start. I believe I should have been monitored more closely and a cesarean should have been performed sooner.'
*13 Oct 06 Detroit: Monroe couple wins $15.8 million in malpractice suit Monroe couple won a $15.8m medical malpractice judgment... involving the birth of their son in 2001... Their lawyer, Brian McKeen of Detroit, said the boy suffered profound brain damage because doctors at Riverside Osteopathic Hospital in Trenton failed to perform a cesarean delivery after Julie Lowe encountered serious problems after going into labor in June 2001.
*30 Aug 06 Brain defect boy gets money, but what use is it? The NCDR forum has ordered the Cosmopolitan Hospital here and 2 doctors to pay Rs.1.1m ($24,300) to the parents of Chakkara... The first mistake took place when the senior gynecologist did not do an immediate cesarean... Geetha was left alone.
*28 Sep 06 Parents win stillborn twin case The parents of a baby boy who was stillborn after clinical negligence have won an out of court settlement... The couple maintained doctors should have performed a caesarean to help Joshua, who was a twin.
*26 Sep 06 Belleville OB sued for not performing emergency C-section
*27 Aug 06 Medical Negligence Case: Justice After 17 years A 17 year-long battle against medical negligence... hospital to pay a compensation of Rs 11.29 lakhs to a couple for causing permanent mental retardation to their son right from his birth in 1989... The commission said the doctors should have gone in for cesarean when there were clear indications of distress to foetus.
*12 Aug 06 Docs get blame for tot death Doctors were yesterday blamed by a coroner for being too slow helping a mother whose child died after she had difficulties during labour... for delaying a caesarean...
*06 Aug 06 Delhi hospital fined for death of baby in womb Finding a Delhi-based hospital guilty of ‘gross medical negligence', a city consumer court has asked it to pay Rs 75,000 as compensation to a woman whose baby died in the womb as the doctors did not opt for cesarean mode of delivery.
*24 May 06 'Breach of duty' in childbirth death Her family claimed she was not seen by a consultant obstetrician for several crucial hours. They argued the medical team should have delivered the baby by emergency caesarean once it was realised Miss Price was in danger of losing her life.
*13 Apr 06 Hospital settles childbirth case A $5m settlement was reached... a Skokie family whose 6-year-old son was born with brain damage at Evanston Hospital in July 1999... Proceeds of the settlement will pay for the care of the boy, who suffers from cerebral palsy.
*03 Apr 06 Brain damage boy, 6, awarded £3m Tzar Stevens Macmillean suffers from severe cerebral palsy caused by a lack of oxygen during his birth at St Mary's Hospital, Manchester, in June 1999.
*18 Mar 06 Award against naval hospital reduced A Fort Lauderdale federal judge...reduced his own verdict in a negligence case against a naval hospital by $20m. But at more than $40m, the judgment still could be the largest personal injury award against the federal government... The judge ruled that doctors and nurses at Jacksonville Naval Hospital waited hours too long to perform a cesarean... As a result, Kevin Rodriguez was born ‘with no heart rate, no respirations, no muscle tone and no muscle reflex.'
*13 Mar 06 Court awards mother compensation A Ballymena woman who was left acutely brain damaged after giving birth in a London hospital has been awarded £500,000 by the High Court... alleged staff were negligent because a caesarean birth was not carried out after his wife developed complications.
*02 Mar 06 Settlement Reached Over C-Section Lawsuit [The woman] was in labor for 27 hours before the decision was made to perform a cesarean.
*05 Oct 02 Mom awarded $8.5 million, Hospital botched son's birth He got stuck in the birth canal for three minutes and was deprived of oxygen. As a result, the baby, Yakeim Donald, was born with severe brain damage. Now 4, he has been diagnosed with cerebral palsy. He cannot speak or walk.

Consider this: it may indeed be possible to reduce the elective cesarean rates in many hospitals, but how many of these will become emergency cesareans instead (which are associated with greater morbidity and mortality risks), and how many will result in injury or death? In fact, the numbers may actually be very small, but for the doctor, midwife and family who are affected by severe complications, that number quickly becomes 100% - because it's happening to them.

Consider too, the implications for birth costs: Planned cesarean deliveries are often criticized for being too costly, but a UK report in 2000 illustrated just how much planned vaginal deliveries cost the NHS when litigation is taken into account: "as much as £50m a year"
*13 Jun 00 An organisation with a memory, Department of Health authored report Every year approximately 50% of the NHS litigation bill relates to claims arising from brain damaged babies. Target set: Negligent harm in obstetrics and gynaecology to be reduced 25% by 2005. It has been estimated that that this could save as much as £50m a year.

And in Los Angeles:
*26 Jan 98 Antonovich ‘shocked' at caesarian policy - calls for investigation
Los Angeles County supervisor: ‘The result of a vaginal birth theory was babies being born deformed, retarded, and in a few cases, dead. In an effort to save money by avoiding cesareans, we cost the taxpayers about $24m so far.'