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Who decides what constitutes a 'normal' birth?

Lindsay Holt
When medical negligence lawyers take on birth injury cases, whether involving harm to the mother or child (more often than not, both), we take the time to carefully review the medical records, discuss them with the family and our experts, to establish whether the care provided fell below an acceptable standard and, if so, whether it caused their injuries.

Often clients say that their treating doctor or midwives told them that they would be having a 'normal' birth and contrast that with an instrumental (forceps or ventouse) delivery, perhaps communicating an unintentional, unspoken message that this intervention is not 'normal'.

Obstetrician Professor Caroline de Costa raised this issue recently in the Guardian, making the point: 
"'Normal vaginal birth' has been polished and praised so much by now that it glows like a lighthouse beacon in much current obstetric and midwifery literature.

Often used interchangeably with 'natural birth' or 'physiological birth', normal birth is defined by the World Health Organization as a birth that is 'spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously [without help] in the vertex position between 37 and 42 completed weeks of pregnancy. After birth mother and baby are in good condition'.

Pregnant women, to qualify, must not go into labour spontaneously before 37 weeks or have labour induced or a caesarean performed for any reason. Their baby must have a headfirst presentation and must not be too big to fit safely through the mother’s birth canal. No instruments can be used to assist vaginal birth, as happened with countless women I’ve delivered with the vacuum, the forceps or by caesar. They also must not bleed excessively'. Did all of these women, then, have “abnormal” births?

The physiological and psychological benefits of WHO’s 'normal birth', if it can be achieved, are undoubted. However, birth may start out as normal but then very quickly become 'not normal'. And even 'normal' births may so stretch and damage the pelvic floor or perineum that long-term incontinence and prolapse are the result."

Professor De Costa asks: "Do the carers – midwives and doctors – have a right to promote 'normal' birth when informing and counselling women about their birth options?"

She is referring to the case of Nadine Montgomery, whose son Sam was born with shoulder dystocia after her treating doctor decided she did not need to know about the risk of a 'normal birth' which they considered was low.  A small framed woman, had she been armed with information about the known risk of having a large baby because of her type 1 diabetes, Ms Montgomery would have requested a caesarean section. She made the point to the Court that it was up to her to decide whether to take the chance on her baby getting stuck during labour and suffering birth hypoxia, not a doctor who might be unaware of her circumstances, and whose advice might have been reasonable but who failed to take account of her views and preferences.

Invariably, our clients rely on the medical and midwifery team to bring their baby safely into the world. If that means a caesarean section, forceps or other intervention, after weighing up the information, for them, that may well be 'normal'. For other parents, normal may be a home birth.

Our experience mirrors Professor De Costa's observation that, 'Overzealous pursuit of “normal” birth has, in some instances, led to compromised safety and care of the mother and baby…'

Our specialist birth injury lawyers have many years' experience offering advice and support to women who have experienced trauma during labour. We are happy to discuss a potential claim with you over the phone and advise the next steps.

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