Original article
Fetal laceration during caesarean section and its medico-legal sequelae
Medicine, Science and the Law 2015, Vol. 55(2) 97–101 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0025802414526181 msl.sagepub.com
Ciro Esposito1, Maria Escolino1, Mariano Paternoster2, Claudio Buccelli2, Vincenzo Graziano2, Marianna Falco2, Francesca Alicchio1, Mariapina Cerulo1, Alessandro Settimi1 and Antonio Savanelli1
Abstract Fetal laceration is a recognized complication of caesarean delivery. The aim of this study was to investigate the incidence, type, location, risk factors and long-term consequences of accidental fetal incised wounds during caesarean delivery. During a five-year period, we observed 25 cases of fetal lacerations caused by the scalpel during hysterotomy. In 20 of these cases, we observed these lesions as consultants for the Neonatologic Care Unit; the other five cases came under our care after an insurance claim for damages against the gynaecologist. All the infants had a lesion located to the head. In only 5 of the 25 cases the lesion was reported in the operative summary, and only 16 of the 25 mothers had signed an informed consent before surgery. With regard to the 20 cases diagnosed at the Neonatologic Care Unit, the lesion was closed using single stitches in nine cases, and with biological glue in 11 cases. Concerning the five cases that underwent legal proceedings against the gynaecologist, a clinical examination was performed by an expert in Public Health and Social Security in collaboration with a paediatric surgeon to evaluate the degree of biological damage. In all five cases, the result of the legal challenge was monetary compensation for the physical and moral damage caused by the gynaecologists to the patients and their parents. Accidental fetal lesions may occur during caesarean delivery; the incidence is significantly higher during emergency caesarean delivery compared to elective procedures. Patients should sign an informed consent in which they should be informed about the risk of the occurrence of fetal lacerations during caesarean delivery in order to avoid legal complications. Keywords Fetal lacerations, caesarean delivery, medico-legal problems, complications
Introduction
increases the risk of maternal and fetal complications. Among the complications of caesarean section, tissue lacerations caused by the scalpel during the incision of the uterine wall are reported. This kind of complication is actually rarely reported, and it seems that its incidence is about 2–6%.3 Twenty-five per cent of these lesions involve body areas of aesthetic relevance, and there are therefore potential legal consequences. Some authors underline that the incidence of fetal lesions after caesarean section is probably underestimated because some
Even nowadays, in some countries, the number of caesarean deliveries is disproportionately higher than dictated by the actual needs of the mother and child, even though the World Health Organization disapproved the improper use of caesarean section after three consensual conferences in 1985.1 Regarding this phenomenon, Italy seems to hold the record for the largest number of caesarean deliveries in Europe. The percentages of caesarean sections vary between 21.1% and 46.9%, according to the data collected in research carried out by the Superior 1 Department of Translational Medical Sciences, Federico II University of Health Institute in 2002, in collaboration with 60 Naples, Italy 2 Department of Public Health and Social Security, Federico II University local health units.2 It is an unacceptable phenomenon of Naples, Italy considering the recommendations of the World Health Organization, which sets a 10% limit in firstCorresponding author: level units and a 15% limit in third-level units.1 Ciro Esposito, Associate Professor of Pediatric Surgery, Federico II Not only does the excessive use of surgery not University of Naples, Via Pansini 5, 80131 Naples, Italy. Email: [email protected] improve perinatal morbidity Downloaded and mortality, it also from msl.sagepub.com at The University of Hong Kong Libraries on August 17, 2015
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cases are not recognized or recorded by the gynaecologists.4–6 The aim of this study was to investigate the incidence, type, location, risk factors and long-term consequences of accidental fetal lacerations during caesarean delivery on the basis of our clinical and medico-legal experience.
Patients and methods During a five-year period, we observed 25 cases of fetal incised wounds caused by the scalpel during hysterotomy. In 20 cases, we observed these lesions as consultants for the Neonatologic Care Unit, while the other five cases came under our care after an insurance claim for damages against the gynaecologists. All the infants had a lesion located to the head. In only 5 of the 25 cases the lesion was reported in the operative summary. Only 16 of the 25 mothers had signed an informed consent before surgery, and the risk of this complication was never reported in the informed consent. The 20 cases treated at birth at the Neonatologic Care Unit presented a lesion located in the following areas: seven to the cranial skin, six to the parietal region, four to the temporal region and three to the cheek. The five cases of lacerations which came under our care after an insurance claim for damages against the surgeons presented the following lesions at the time of our observation: Case 1. At the age of five months, a 13 cm, pearly grey, horizontal surgical scar was present in the right frontoparietal region, 8 cm of which was completely visible in the frontal region, with moderate infiltration of the soft tissue in the frontal extremity (Figure 1). Case 2. At the age of 14 months, a 4 cm surgical scar, with slightly diastatic edges and with a small sagging area in its distal third, was present in the right temporal region and was clearly visible at a conversation distance (Figure 2).
Figure 1. A 13 cm horizontal surgical scar in the right frontoparietal region (Case 1).
Case 3. At the age of four months, a hypochromic area (3 cm 2 cm) was present in the left frontoparietal region and was visible at a conversation distance (Figure 3). Case 4. At the age of 36 months, a 3 cm transversal, slightly hyperchromic and stiff, surgical scar was present on the left cheek and was clearly visible at a conversation distance (Figure 4). Case 5. At the age of three years, a hyperchromic and prominent surgical scar (2 cm 1.5 cm) was visible in the left parietal region, almost entirely covered by hair (Figure 5).
Results In the 20 cases diagnosed at the Neonatologic Care Unit, the lesion was closed using separated stitches in nine cases, and with biological glue in 11 patients (Figure 6). In the five cases that underwent legal proceedings against the gynaecologists, all patients
Figure 2. A 4 cm surgical scar in the right temporal region (Case 2).
Figure 3. A 3 cm 2 cm hypochromic area in the left frontoparietal region (Case 3).
Downloaded from msl.sagepub.com at The University of Hong Kong Libraries on August 17, 2015
Esposito et al.
99 received a clinical examination to evaluate the degree of biological damage. This examination was performed by an expert in Public Health and Social Security in collaboration with a paediatric surgeon as technical expert. The biological damage caused by the lesions was evaluated as follows:
Figure 4. A 3 cm surgical scar on the left cheek (Case 4).
Figure 5. A 2 cm 1.5 cm surgical scar in the left parietal region (Case 5).
Case 1. We evaluated the biological damage of this lesion equal to 8% (a 13 cm horizontal surgical scar in the right frontoparietal region, 8 cm of which was completely visible in the frontal region). Case 2. We evaluated the biological damage of this lesion equal to 6% (a 4 cm rosy surgical scar in the right temporal region). Case 3. We evaluated the biological damage of this lesion equal to 2% (a 3 cm 2 cm hypochromic area in the left frontoparietal region). Case 4. We evaluated the biological damage of this lesion equal to 3–4% (a 3 cm, transversal, slightly hyperchromic surgical scar on the left cheek). Case 5. We evaluated the biological damage of this lesion equal to 1–2% (a 2 cm 1.5 cm, hyperchromic and prominent surgical scar in the left parietal region, almost entirely covered by hair). We decided that the scars – in all cases located to the head, and, in some children, visible at a conversation distance – caused a permanent physical alteration and aesthetic damage to the children. The degree of permanent disability was assessed by assigning a percentage score. The amount of compensation was calculated by applying specific tables that indicate an amount of money for each percentage point of disability. In all five cases, the result of the legal challenge was monetary compensation for the physical lesions and moral damage caused by gynaecological mistakes to the patients and their parents.
Figure 6. A scalp incision detected at birth at the Neonatologic Care Unit and repaired with biological glue. Downloaded from msl.sagepub.com at The University of Hong Kong Libraries on August 17, 2015
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Discussion
Medicine, Science and the Law 55(2) with fewer injuries (0.5%). The type of uterine incision is another important risk factor: 3.4% in T-incisions or J-incisions, 1.4% in vertical incisions and 1.1% in lower transverse incisions. The rapidity of execution is also connected to fetal damage, with a time interval of more than three minutes between incision and delivery being another risk factor. The gynaecologist’s attention should be focused on identifying all potential maternal and fetal risk factors that may cause fetal complications during caesarean delivery. An appropriate set of rules and procedures may prevent the occurrence of fetal lesions. These include administering adequate analgesia, extracting the fetus using delicate traction, and performing a uterine incision that is sufficiently wide to allow easy extraction. In this regard, extending the uterine incision is recommended rather than continuing to exert traction that may be difficult and/or dangerous. These recommendations represent the right approach for early detection of possible complications, such as head lacerations, skin lacerations and fractures lacerations, in order to prepare for prompt treatment of the occurring complication. In cases of fetal lacerations during caesarean section, evaluation of the surgeon’s professional conduct must include the counselling that the pregnant woman received about the risk of complications, and also the use of procedures suggested by the scientific literature to reduce the incidence of lesions. Adopting the precautions suggested by the literature in order to prevent fetal lesions (if permitted by maternal–fetal conditions) is mandatory, even if these procedures are not yet well established, although they do not guarantee that lesions will not occur – and the mother must be made aware of that. The written informed consent before caesarean delivery should inform the patient about all of the various traumatic fetal complications of caesarean section, such as head lacerations, skin lacerations and fracture lacerations, that could occur even if the caesarean section is performed by a skilled gynaecologist. The guidelines commissioned by the National Institute for Health and Clinical Excellence (NICE) (National Collaborating Centre for Women’s and Children’s Health, ‘Caesarean Section’, April 2004) recommend that women who undergo a caesarean section should be informed that the risk of fetal lacerations is about 2%.15 Examining our five cases, interesting data emerged for forensic medicine. In all cases, we noted:
In Italy, court actions against surgeons have represented a significant problem in the last 10 years. It seems that during their career, every four to five surgeons have at least one legal proceeding linked to their surgical activity. This is particularly common in the areas of gynaecology and paediatrics. Fetal damage during caesarean section is a serious adverse effect, and American case studies confirm this point. Baxter et al. reported that every year more than 13,000 newborns in the USA show lesions after delivery by caesarean section.7 Capobianco et al. stated that caesarean delivery reduces the risk of traumatic injury to the newborn compared to vaginal delivery, especially with breech presentation, but it does not eliminate this possible accidental complication.8 Among these lesions, lacerations to both superficial and deep tissue are reported. The percentage of fetal incised wounds is overall quite small (their incidence is about 1.5–6%), but it is an underestimated phenomenon, as sometimes these lesions are not documented by surgeons in the operative summary.9 The lesions are often discovered by nurses or neonatologists, especially if they need sutures. In general, paediatric surgeons are called upon to repair these lesions using sutures or glue. Wiener et al. stated that the incidence of this complication was linked to the type of surgical section, fetal presentation, cervical dilation, membrane integrity and the experience of the surgeon. They suggested that this complication should be included in the informed consent given to all women who are to undergo caesarean section.10 As for the type of lesions, the majority involves only the skin, and the consequences are fundamentally aesthetic, with almost no long-term disability. However, there are also more serious lesions such as fractures or lesions affecting the nerves or eyes that have significant consequences for the affected infants.8,11–14 In general, skin lesions can be treated immediately with good aesthetic results. However, parents consider fetal lacerations during caesarean section a serious complication because of the obvious iatrogenic origin. Therefore, these lesions often have legal consequences. The current literature on this topic is poor, but it allows us to identify some of the maternal risk factors linked to a higher incidence of the complication (abnormal presentation, premature rupture of membranes, emergency procedures, low quantity of amniotic fluid, etc.), and the opportunities for gynaecologists to reduce the risk of fetal lacerations (a) poor attention to preliminary information and using some precautions during the hysterotomy.4,5 consent to caesarean section; (b) an absence of information to pregnant women It seems that caesarean deliveries performed after a about the risk of fetal lesions during caesarean failed attempt at delivery using forceps or suction delivery; cups cause the highest number of injuries (6.9% in (c) a widespread trend to fill the surgical register with first caesarean deliveries; 1.7% in others) compared poor information and incomplete descriptions of to elective caesarean sections, which are associated Downloaded from msl.sagepub.com at The University of Hong Kong Libraries on August 17, 2015
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surgical techniques/manoeuvres (especially the type of uterine incision); (d) a tendency to report the fetal lacerations by the surgeon and especially by the paediatrician with an accurate description of the lesion; (e) permanent damage, especially aesthetic, caused by scars on the face, often with low residual disability. Even if these lesions can be justified in the context of the risk factors for fetal lesions, in every single examined case there were flaws in the surgeons’ professional conduct because the information and the consent to caesarean section were incomplete, and the management of the complication was inadequate (in fact, the procedures performed to protect the health of the newborn were not described). In all five cases that we examined, the result of the legal challenge was monetary compensation for the moral and physical damage caused by the gynaecologists to the patients and their parents.
Conclusions Accidental fetal lacerations may occur during caesarean delivery; the incidence is significantly higher during emergency caesarean delivery compared to elective procedures. Patients should sign an informed consent in which they should be adequately informed about the occurrence of fetal lesions during caesarean delivery in order to avoid legal complications. Medico-legal consequences may be significant. In our opinion, an appropriate set of rules and procedures used by gynaecologists during a caesarean section and correct information given to the parents with detailed informed consent might reduce the demand for legal proceedings for compensation against gynaecologists. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Declaration of conflicting interest All authors declare that they have no conflict of interest.
References 1. World Health Organization. Appropriate technology for birth. Lancet 1985; 326: 436–437. 2. Grandolfo M, Donati S and Giusti A. Indagine conoscitiva sul percorso nascita. Aspetti metodologici e risultati nazionali. Roma: Istituto Superiore di Sanita`, 2002, www.epicentro.iss.it/problemi/percorso-nascita/indpdf/nascita-1.pdf. 3. Smith JF, Hernandez C and Wax JR. Fetal laceration injury at cesarean delivery. Obstet Gynecol 1997; 90: 344–346. 4. Aburezq H, Chakrabarty KH and Zuker RM. Iatrogenic fetal injury. Obstet Gynecol 2005; 106: 1172–1174. 5. Alexander JM, Leveno KJ, Hauth J, et al. Fetal injury associated with cesarean delivery. Obstet Gynecol 2006; 108: 885–890. 6. Dessole S, Cosmi E, Balata A, et al. Accidental fetal lacerations during cesarean delivery: Experience in an Italian level III University hospital. Am J Obstet Gynecol 2004; 191: 1673–1677. 7. Baxter JK, Boyle K and Weinstein L. Fetal injury associated with cesarean delivery. Obstet Gynecol 2006; 108: 885–890. 8. Capobianco G, Virdis G, Lisai P, et al. Cesarean section and right femur fracture: A rare but possible complication for breech presentation. Case Rep Obstet Gynecol 2013; 2013: 613709. 9. Haas DM and Ayres AW. Laceration injury at cesarean section. J Matern Fetal Neonatal Med 2002; 11: 196–198. 10. Wiener JJ and Westwood J. Fetal lacerations at caesarean section. Obstet Gynecol 2002; 22: 23–24. 11. Rinker B. Extensor tendon injury during cesarean delivery. J Hand Surg Am 2010; 36: 125–128. 12. Gajjar K and Spencer C. Fetal laceration injury during cesarean section and its long-term sequelae: A case report. Am J Obstet Gynecol 2009; 201: 5–7. 13. Kaplan M, Dollberg M, Wajntraub G, et al. Fractured long bones in a term infant delivered by cesarian section. Pediatr Radiol 1987; 17: 256–257. 14. Tan EK. Difficult caesarean delivery of an impacted head and neonatal skull fracture: Can the morbidity be avoided? Obstet Gynecol 2007; 27: 427–428. 15. National Institute for Health and Clinical Excellence (NICE). National Collaborating Centre for Women’s and Children’s Health. ‘Caesarean Section’ (April 2004) RCOG Press at the Royal College of Obstetricians and Gynecologist, London. http://guidance.nice.org.uk/CG13.
Downloaded from msl.sagepub.com at The University of Hong Kong Libraries on August 17, 2015
Fetal laceration during caesarean section and its medico-legal sequelae
Medicine, Science and the Law 2015, Vol. 55(2) 97–101 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0025802414526181 msl.sagepub.com
Ciro Esposito1, Maria Escolino1, Mariano Paternoster2, Claudio Buccelli2, Vincenzo Graziano2, Marianna Falco2, Francesca Alicchio1, Mariapina Cerulo1, Alessandro Settimi1 and Antonio Savanelli1
Abstract Fetal laceration is a recognized complication of caesarean delivery. The aim of this study was to investigate the incidence, type, location, risk factors and long-term consequences of accidental fetal incised wounds during caesarean delivery. During a five-year period, we observed 25 cases of fetal lacerations caused by the scalpel during hysterotomy. In 20 of these cases, we observed these lesions as consultants for the Neonatologic Care Unit; the other five cases came under our care after an insurance claim for damages against the gynaecologist. All the infants had a lesion located to the head. In only 5 of the 25 cases the lesion was reported in the operative summary, and only 16 of the 25 mothers had signed an informed consent before surgery. With regard to the 20 cases diagnosed at the Neonatologic Care Unit, the lesion was closed using single stitches in nine cases, and with biological glue in 11 cases. Concerning the five cases that underwent legal proceedings against the gynaecologist, a clinical examination was performed by an expert in Public Health and Social Security in collaboration with a paediatric surgeon to evaluate the degree of biological damage. In all five cases, the result of the legal challenge was monetary compensation for the physical and moral damage caused by the gynaecologists to the patients and their parents. Accidental fetal lesions may occur during caesarean delivery; the incidence is significantly higher during emergency caesarean delivery compared to elective procedures. Patients should sign an informed consent in which they should be informed about the risk of the occurrence of fetal lacerations during caesarean delivery in order to avoid legal complications. Keywords Fetal lacerations, caesarean delivery, medico-legal problems, complications
Introduction
increases the risk of maternal and fetal complications. Among the complications of caesarean section, tissue lacerations caused by the scalpel during the incision of the uterine wall are reported. This kind of complication is actually rarely reported, and it seems that its incidence is about 2–6%.3 Twenty-five per cent of these lesions involve body areas of aesthetic relevance, and there are therefore potential legal consequences. Some authors underline that the incidence of fetal lesions after caesarean section is probably underestimated because some
Even nowadays, in some countries, the number of caesarean deliveries is disproportionately higher than dictated by the actual needs of the mother and child, even though the World Health Organization disapproved the improper use of caesarean section after three consensual conferences in 1985.1 Regarding this phenomenon, Italy seems to hold the record for the largest number of caesarean deliveries in Europe. The percentages of caesarean sections vary between 21.1% and 46.9%, according to the data collected in research carried out by the Superior 1 Department of Translational Medical Sciences, Federico II University of Health Institute in 2002, in collaboration with 60 Naples, Italy 2 Department of Public Health and Social Security, Federico II University local health units.2 It is an unacceptable phenomenon of Naples, Italy considering the recommendations of the World Health Organization, which sets a 10% limit in firstCorresponding author: level units and a 15% limit in third-level units.1 Ciro Esposito, Associate Professor of Pediatric Surgery, Federico II Not only does the excessive use of surgery not University of Naples, Via Pansini 5, 80131 Naples, Italy. Email: [email protected] improve perinatal morbidity Downloaded and mortality, it also from msl.sagepub.com at The University of Hong Kong Libraries on August 17, 2015
98
Medicine, Science and the Law 55(2)
cases are not recognized or recorded by the gynaecologists.4–6 The aim of this study was to investigate the incidence, type, location, risk factors and long-term consequences of accidental fetal lacerations during caesarean delivery on the basis of our clinical and medico-legal experience.
Patients and methods During a five-year period, we observed 25 cases of fetal incised wounds caused by the scalpel during hysterotomy. In 20 cases, we observed these lesions as consultants for the Neonatologic Care Unit, while the other five cases came under our care after an insurance claim for damages against the gynaecologists. All the infants had a lesion located to the head. In only 5 of the 25 cases the lesion was reported in the operative summary. Only 16 of the 25 mothers had signed an informed consent before surgery, and the risk of this complication was never reported in the informed consent. The 20 cases treated at birth at the Neonatologic Care Unit presented a lesion located in the following areas: seven to the cranial skin, six to the parietal region, four to the temporal region and three to the cheek. The five cases of lacerations which came under our care after an insurance claim for damages against the surgeons presented the following lesions at the time of our observation: Case 1. At the age of five months, a 13 cm, pearly grey, horizontal surgical scar was present in the right frontoparietal region, 8 cm of which was completely visible in the frontal region, with moderate infiltration of the soft tissue in the frontal extremity (Figure 1). Case 2. At the age of 14 months, a 4 cm surgical scar, with slightly diastatic edges and with a small sagging area in its distal third, was present in the right temporal region and was clearly visible at a conversation distance (Figure 2).
Figure 1. A 13 cm horizontal surgical scar in the right frontoparietal region (Case 1).
Case 3. At the age of four months, a hypochromic area (3 cm 2 cm) was present in the left frontoparietal region and was visible at a conversation distance (Figure 3). Case 4. At the age of 36 months, a 3 cm transversal, slightly hyperchromic and stiff, surgical scar was present on the left cheek and was clearly visible at a conversation distance (Figure 4). Case 5. At the age of three years, a hyperchromic and prominent surgical scar (2 cm 1.5 cm) was visible in the left parietal region, almost entirely covered by hair (Figure 5).
Results In the 20 cases diagnosed at the Neonatologic Care Unit, the lesion was closed using separated stitches in nine cases, and with biological glue in 11 patients (Figure 6). In the five cases that underwent legal proceedings against the gynaecologists, all patients
Figure 2. A 4 cm surgical scar in the right temporal region (Case 2).
Figure 3. A 3 cm 2 cm hypochromic area in the left frontoparietal region (Case 3).
Downloaded from msl.sagepub.com at The University of Hong Kong Libraries on August 17, 2015
Esposito et al.
99 received a clinical examination to evaluate the degree of biological damage. This examination was performed by an expert in Public Health and Social Security in collaboration with a paediatric surgeon as technical expert. The biological damage caused by the lesions was evaluated as follows:
Figure 4. A 3 cm surgical scar on the left cheek (Case 4).
Figure 5. A 2 cm 1.5 cm surgical scar in the left parietal region (Case 5).
Case 1. We evaluated the biological damage of this lesion equal to 8% (a 13 cm horizontal surgical scar in the right frontoparietal region, 8 cm of which was completely visible in the frontal region). Case 2. We evaluated the biological damage of this lesion equal to 6% (a 4 cm rosy surgical scar in the right temporal region). Case 3. We evaluated the biological damage of this lesion equal to 2% (a 3 cm 2 cm hypochromic area in the left frontoparietal region). Case 4. We evaluated the biological damage of this lesion equal to 3–4% (a 3 cm, transversal, slightly hyperchromic surgical scar on the left cheek). Case 5. We evaluated the biological damage of this lesion equal to 1–2% (a 2 cm 1.5 cm, hyperchromic and prominent surgical scar in the left parietal region, almost entirely covered by hair). We decided that the scars – in all cases located to the head, and, in some children, visible at a conversation distance – caused a permanent physical alteration and aesthetic damage to the children. The degree of permanent disability was assessed by assigning a percentage score. The amount of compensation was calculated by applying specific tables that indicate an amount of money for each percentage point of disability. In all five cases, the result of the legal challenge was monetary compensation for the physical lesions and moral damage caused by gynaecological mistakes to the patients and their parents.
Figure 6. A scalp incision detected at birth at the Neonatologic Care Unit and repaired with biological glue. Downloaded from msl.sagepub.com at The University of Hong Kong Libraries on August 17, 2015
100
Discussion
Medicine, Science and the Law 55(2) with fewer injuries (0.5%). The type of uterine incision is another important risk factor: 3.4% in T-incisions or J-incisions, 1.4% in vertical incisions and 1.1% in lower transverse incisions. The rapidity of execution is also connected to fetal damage, with a time interval of more than three minutes between incision and delivery being another risk factor. The gynaecologist’s attention should be focused on identifying all potential maternal and fetal risk factors that may cause fetal complications during caesarean delivery. An appropriate set of rules and procedures may prevent the occurrence of fetal lesions. These include administering adequate analgesia, extracting the fetus using delicate traction, and performing a uterine incision that is sufficiently wide to allow easy extraction. In this regard, extending the uterine incision is recommended rather than continuing to exert traction that may be difficult and/or dangerous. These recommendations represent the right approach for early detection of possible complications, such as head lacerations, skin lacerations and fractures lacerations, in order to prepare for prompt treatment of the occurring complication. In cases of fetal lacerations during caesarean section, evaluation of the surgeon’s professional conduct must include the counselling that the pregnant woman received about the risk of complications, and also the use of procedures suggested by the scientific literature to reduce the incidence of lesions. Adopting the precautions suggested by the literature in order to prevent fetal lesions (if permitted by maternal–fetal conditions) is mandatory, even if these procedures are not yet well established, although they do not guarantee that lesions will not occur – and the mother must be made aware of that. The written informed consent before caesarean delivery should inform the patient about all of the various traumatic fetal complications of caesarean section, such as head lacerations, skin lacerations and fracture lacerations, that could occur even if the caesarean section is performed by a skilled gynaecologist. The guidelines commissioned by the National Institute for Health and Clinical Excellence (NICE) (National Collaborating Centre for Women’s and Children’s Health, ‘Caesarean Section’, April 2004) recommend that women who undergo a caesarean section should be informed that the risk of fetal lacerations is about 2%.15 Examining our five cases, interesting data emerged for forensic medicine. In all cases, we noted:
In Italy, court actions against surgeons have represented a significant problem in the last 10 years. It seems that during their career, every four to five surgeons have at least one legal proceeding linked to their surgical activity. This is particularly common in the areas of gynaecology and paediatrics. Fetal damage during caesarean section is a serious adverse effect, and American case studies confirm this point. Baxter et al. reported that every year more than 13,000 newborns in the USA show lesions after delivery by caesarean section.7 Capobianco et al. stated that caesarean delivery reduces the risk of traumatic injury to the newborn compared to vaginal delivery, especially with breech presentation, but it does not eliminate this possible accidental complication.8 Among these lesions, lacerations to both superficial and deep tissue are reported. The percentage of fetal incised wounds is overall quite small (their incidence is about 1.5–6%), but it is an underestimated phenomenon, as sometimes these lesions are not documented by surgeons in the operative summary.9 The lesions are often discovered by nurses or neonatologists, especially if they need sutures. In general, paediatric surgeons are called upon to repair these lesions using sutures or glue. Wiener et al. stated that the incidence of this complication was linked to the type of surgical section, fetal presentation, cervical dilation, membrane integrity and the experience of the surgeon. They suggested that this complication should be included in the informed consent given to all women who are to undergo caesarean section.10 As for the type of lesions, the majority involves only the skin, and the consequences are fundamentally aesthetic, with almost no long-term disability. However, there are also more serious lesions such as fractures or lesions affecting the nerves or eyes that have significant consequences for the affected infants.8,11–14 In general, skin lesions can be treated immediately with good aesthetic results. However, parents consider fetal lacerations during caesarean section a serious complication because of the obvious iatrogenic origin. Therefore, these lesions often have legal consequences. The current literature on this topic is poor, but it allows us to identify some of the maternal risk factors linked to a higher incidence of the complication (abnormal presentation, premature rupture of membranes, emergency procedures, low quantity of amniotic fluid, etc.), and the opportunities for gynaecologists to reduce the risk of fetal lacerations (a) poor attention to preliminary information and using some precautions during the hysterotomy.4,5 consent to caesarean section; (b) an absence of information to pregnant women It seems that caesarean deliveries performed after a about the risk of fetal lesions during caesarean failed attempt at delivery using forceps or suction delivery; cups cause the highest number of injuries (6.9% in (c) a widespread trend to fill the surgical register with first caesarean deliveries; 1.7% in others) compared poor information and incomplete descriptions of to elective caesarean sections, which are associated Downloaded from msl.sagepub.com at The University of Hong Kong Libraries on August 17, 2015
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surgical techniques/manoeuvres (especially the type of uterine incision); (d) a tendency to report the fetal lacerations by the surgeon and especially by the paediatrician with an accurate description of the lesion; (e) permanent damage, especially aesthetic, caused by scars on the face, often with low residual disability. Even if these lesions can be justified in the context of the risk factors for fetal lesions, in every single examined case there were flaws in the surgeons’ professional conduct because the information and the consent to caesarean section were incomplete, and the management of the complication was inadequate (in fact, the procedures performed to protect the health of the newborn were not described). In all five cases that we examined, the result of the legal challenge was monetary compensation for the moral and physical damage caused by the gynaecologists to the patients and their parents.
Conclusions Accidental fetal lacerations may occur during caesarean delivery; the incidence is significantly higher during emergency caesarean delivery compared to elective procedures. Patients should sign an informed consent in which they should be adequately informed about the occurrence of fetal lesions during caesarean delivery in order to avoid legal complications. Medico-legal consequences may be significant. In our opinion, an appropriate set of rules and procedures used by gynaecologists during a caesarean section and correct information given to the parents with detailed informed consent might reduce the demand for legal proceedings for compensation against gynaecologists. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Declaration of conflicting interest All authors declare that they have no conflict of interest.
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