Re CA (Natural Delivery or Caesarean Section)
This case concerned a 24 year old woman, CA, with a diagnosis of autism and a mild learning disability who, it was thought, had undergone some form of female genital mutilation as a child. CA was very reluctant to allow herself to be examined and had only agreed to limited examination of the foetus during her pregnancy. She did not want to go to hospital, saying it was associated with too many bad memories of her childhood and her life. She wanted to give birth at home on her own. She appeared to have little or no understanding of what giving birth would be like, and the expert evidence was that her failure to take relevant information into account was the direct consequence of her autism.
Baker J concluded that CA lacked capacity to make decisions about the method of delivery, and a detailed balance sheet was drawn up comparing the options of a planned caesarean section and vaginal delivery. The treating doctors considered that 'taking into account her history of non-compliance and lack of capacity to consent to surgical intervention, an elective Caesarean section would be the safest, least traumatic and most appropriate mode of delivery.' A consultant psychiatrist expressed the view that the 'option of a vaginal delivery was unrealistic due to CA's refusal to allow the midwife to carry out repeated vaginal examinations to monitor the progress of her labour; her refusal to talk through various options for pain relief; her refusal to allow administration of any necessary injectable medication if required; her anticipation that the baby would just "pop out"; her lack of realisation that the experience of first delivery may be long and often painful; her reluctance to comply with instructions and the consequent risk of lack of cooperation, for example when instructed to push, leading to an uncoordinated or chaotic labour process.' Dr I also expressed the view, which the court accepted, that 'an emergency Caesarean section would cause the greatest degree of psychological damage to CA, and that a planned Caesarean section is likely to lead to the least psychological damage of the options in this case.'
Baker J authorised a plan for a caesarean section to include sedation and physical restraint if necessary.
As is common in these cases, the application was brought very late – less than two weeks before the due date. Baker J was very critical of the Trust's failure to follow the clear guidance previously given by the court about the need for prompt applications, and it is likely that in future cases, applications at short notice are likely to result in serious criticism and/or costs consequences for Trusts.
It is unsurprising given the unanimous medical evidence that the Trust's proposals were endorsed by the court, despite going against CA's clearly expressed wishes. A postscript to the judgment notes that CA's baby was born with minimal restraint to hold her hand to administer intravenous sedation, and that her baby was in the breech position.