Dear Editor
Birth Trauma organisations advocate on behalf of women and babies who
have experienced adverse outcomes and naturally they will take a
risk-averse perspective on birth-related care. The latest version of the
Assisted Vaginal Birth (AVB) RCOG Guideline (previously called Operative
Vaginal Delivery) has focussed specifically on revisions designed to
minimise the risk of traumatic injuries for the mother and baby.1 The landmark Montgomery ruling that raised the bar
on the standard required for informed consent has been embraced and
endorsed within the guideline. 2 It is disappointing
to read that Hull et al have concluded that “Montgomery is
missing from RCOG’s Assisted Vaginal Birth
guideline”.3
Hull et al have acknowledged the important counselling advice
that has been recommended – antenatal discussion about AVB when
planning birth in the third trimester (especially for first-time
mothers), review of birth preferences when conducting routine labour
ward rounds, and in depth counselling, where circumstances allow, if
complications arise during the course of labour particularly during the
second stage. However, the guideline apparently falls short of the
Montgomery ruling in that we have not recommended “planned caesarean”
as an option to prevent assisted vaginal birth.
The AVB guideline went through an extensive scoping process. The agreed
scope was to address all key questions that arise in relation to
labouring women who may require obstetric assistance in the second stage
of labour - the assumption being that these women have the intention to
labour and deliver vaginally. A guideline addressing maternal request
“planned” caesarean section is an entirely different guideline. It is
also incorrect to state that the RCOG have provided no direct guidance
on this (see Choosing to have a Caesarean section , RCOG Patient
Information (2015) based on NICE Clinical Guideline Caesarean
Section (2011)).4 The issue of pelvic floor morbidity
was included in the literature search and has been discussed in detail.
The Montgomery ruling related to a woman with diabetes in pregnancy and
a large for gestational age fetus who experienced shoulder dystocia
resulting in her baby developing cerebral palsy. The importance of
outlining, in advance, the birth options for this woman is clear, given
the specific known risks associated with labour in her circumstances.
Hull et al suggest on the same basis that all women should be
advised that a planned caesarean section is an option to prevent
assisted vaginal birth. If taken one step further the Montgomery ruling
could be cited to support the argument that all women should be advised
that the best way to avoid pregnancy-related complications is to avoid
getting pregnant. Common sense would infer that this was not the
intention of the Montgomery ruling.
Where this RCOG guideline is likely to be consistent with Birth Trauma
organisations is in the recommendations on careful assessment,
supervision and decision-making; clear communication and transparent
consent procedures; and an overall approach that places safety as the
first priority when deciding when and when not to attempt a vacuum or
forceps assisted delivery, and when to discontinue any such attempt. It
is hoped that all relevant health professionals will review and
implement the evidence-based, peer-reviewed recommendations within this
guideline. They are designed to support women in achieving safe and
joyful births, even when obstetric assistance is required.
Deirdre J Murphy,1 Rachna Bahl,2Bryony Strachan2
1) Coombe Women & Infants University Hospital
Cork St, Dublin 8, Republic of Ireland
2) St Michael’s Hospital, Bristol