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\begin{document}

\title{Re: Assisted Vaginal Birth: Green-top Guideline No. 26}



\author[1]{Pauline McDonagh Hull}%
\author[2]{Kim Thomas}%
\author[3]{Elizabeth Skinner}%
\author[4]{Amy Dawes}%
\author[5]{Penny Christensen}%
\affil[1]{University of Calgary Department of Community Health Sciences}%
\affil[2]{Birth Trauma Organisation}%
\affil[3]{The University of Sydney}%
\affil[4]{Australasian Birth Trauma Association}%
\affil[5]{Birth Trauma Canada}%


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  \date{May 27, 2024}


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Just weeks following the fifth anniversary of the landmark Montgomery v
Lanarkshire Health Board Supreme Court judgment, the Royal College of
Obstetricians and Gynaecologists (RCOG) has delivered the fourth edition
of its Green-top guideline on forceps and vacuum assisted
births\textsuperscript{1}. The irony of this is not lost on those who
expected real change following last year's peer review consultation (19
physicians and 6 maternity care organisations responded, including the
first two signatories of this letter). The guideline opens with a
fundamental question: \emph{Can assisted vaginal birth be avoided?} The
answers RCOG provides are solely in the context of labour (evidence on
continuous support, epidural analgesia, positions adopted, delayed
pushing), but a legal interpretation of Montgomery advises birth is ``a
situation that allows for significant advance planning and accordingly
plans must be made.''\textsuperscript{2} The guideline concurs: women
``should be informed about assisted vaginal birth in the antenatal
period, especially during their first pregnancy {[}and{]} in advance of
labour''. Nevertheless, while ``lower rates in midwifery-led care
settings'' is included, `lower rates with planned caesarean' is not, and
there is no direct equivalent Green-top for this birth mode. The
Montgomery judgment on consent specifically states that doctors are
``under a duty to take reasonable care to ensure that the patient is
aware of any material risks involved in any recommended treatment, and
of any reasonable alternative or variant treatments.'' It also
emphasises that in any pregnancy, the ``principal choice is between
vaginal delivery and caesarean section.'' RCOG may argue that
referencing the ``alternative choice of a caesarean section late in the
second stage of labour'' sufficiently addresses these points. However, a
Queen's Counsel who was involved in the Montgomery case reminds doctors
that the mother ``was not advised that an alternative to vaginal birth
(i.e. caesarean section) was an option available to her\ldots{} and
there was an increased risk\ldots{} should vaginal birth be
attempted.''\textsuperscript{2} He warns, ``Where the patient asks a
question, it must be answered honestly and fully'', which suggests that
planned caesarean birth omission from this Green-top could have serious
legal consequences, and there is every chance the Montgomery case could
reoccur.

Despite aiming ``to provide evidence-based recommendations'', RCOG does
not include pelvic organ prolapse as an adverse outcome. Instead, it
says women who ``achieve an assisted vaginal birth rather than have a
caesarean birth\ldots{} are far more likely to have an uncomplicated
vaginal birth in subsequent pregnancies'', and that ``much of the pelvic
floor morbidity reported\ldots{} may not be causally related to the
procedure.'' Furthermore, the stated aim of RCOG's clinical Green-tops
is to identify ``good practice and desired outcomes'', which will be
``used globally.''\textsuperscript{4} This is relevant because many
countries define this as low caesarean birth rates. In the UK, the
National Institute for Health and Care Excellence (NICE) does not
advocate targets, and recommends support for prophylactic caesarean
birth requests.\textsuperscript{3} Yet decades of promoting vaginal
birth rather than informed choice has obstructed autonomy and
contributed substantially to rising litigation
costs.\textsuperscript{5}The truth is, the NHS simply cannot afford to
keep repeating the same communication and consent mistakes, and in our
view, this NICE accredited Green-top guideline clearly demonstrates that
lessons from Montgomery have still not been learned.

Pauline M Hull, Founder, Caesarean Birth

Kim Thomas, CEO, Birth Trauma Organisation

Dr. Elizabeth Skinner, Faculty of Medicine, University of Sydney

Amy Dawes, Co-founder and CEO, Australasian Birth Trauma Association

Penny Christensen, Executive Director, Birth Trauma Canada

\emph{References}

1. Murphy DJ, Strachan BK, Bahl R, on behalf of the Royal College of
Obstetricians Gynaecologists.

Assisted Vaginal Birth. BJOG 2020;
https://doi.org/10.1111/1471-0528.16092

2. Smith, A. (2017). Montgomery and implications for clinical
practice.~\emph{BJOG: An International Journal of Obstetrics and
Gynaecology,} ~\emph{124} (8), 1148-1151.

3. National Institute for Health and Care Excellence. Caesarean section
(update). CG132. 2011.~http://guidance.nice.org.uk/CG132. 4. Royal
College of Obstetricians and Gynaecologists. Developing a Green-top
Guideline. London: RCOG; 2020. 5. West, J., Taylor, M., \& Magro, M.
(2019). The true relative financial costs of Planned Caesarean Section
(PCS) versus Planned Vaginal Birth (PVB) in England taking into account
litigation and compensation for harm.~\emph{F1000Research, 8} .
doi.org/10.7490/f1000research.1.\emph{Disclosure of interests}

Pauline M Hull is co-author of Choosing Cesarean, A Natural Birth Plan,
and editor of caesareanbirth.org

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