Response Royal College of Obstetricians Gynaecologists
Education
Action Planned
The RCOG patient information leaflet, "Birth options after previous caesarean section," has been reviewed and updated to include information about the potential fatal consequences of uterine rupture for both mother and baby and is due for publication in the very near future. (AI summary)
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Dear Mr Sowersby
Re: Baby Mabel Olivia Williams
Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of Baby Mabel on 8 September 2025.
The loss of a baby is a devastating tragedy for parents, the wider family, and healthcare professionals involved. We would like to begin by extending our deepest and heartfelt condolences to Mabel’s family for their profound loss.
This response has been developed following input from members of the Royal College of Obstetricians and Gynaecologists (RCOG) Patient Safety Committee and Senior Officers of the College.
We recognise and respect the narrative conclusion from the inquest. The medical cause of Mabel’s death was:
1a) Severe hypoxic ischaemic encephalopathy, 1b) Undiagnosed uterine rupture.
We also recognise the matters of concern as outlined in your letter as follows, When Becky (Mabel’s mother) was advised about VBAC she was referred to internal guidance from the hospital and to the RCOG’s information leaflet “Birth options after previous caesarean section” (published in July 2016). I reviewed the information leaflet and it does not contain any indication that uterine rupture could potentially prove fatal for mother and / or baby. My concern is that prospective parents may rely on this information leaflet to assist them in making informed choices about their birth options, and that if the risk is not identified then other patients like Becky might pursue VBAC in circumstances where – if they had understood the risk better – they would have chosen otherwise.
The purpose of RCOG patient information leaflet is to convey essential information in an accessible format. It aims to support the individualised discussion between the clinician and the woman and their partner and/or other friends and family and is not intended to be a stand-alone resource.
All our patient information leaflets are produced in collaboration with service users and clinicians to try to ensure that they convey information that is accurate, relevant, clear and succinct. The depth of information is agreed after very careful consideration, and with input from service users and clinicians, and highlights that additional conversations with clinicians are needed to help personalise the risks for an individual.
In response to your concerns, this patient information leaflet is based on the RCOG Green-top Guideline No 45 Birth After Previous Caesarean Birth1 (October 2015). The Green-top Guideline states that uterine rupture is a rare but serious complication associated with maternal and perinatal morbidity and mortality:
Women should be informed that the absolute risk of birth-related perinatal death associated with VBAC is extremely low and comparable to the risk for nulliparous women in labour.
Women should be informed of the two-to-three-fold increased risk of uterine rupture and around 1.5- fold increased risk of caesarean birth in induced and/or augmented labour compared with spontaneous VBAC labour.
Approximately 0.5% risk of uterine scar rupture. If occurs, associated with maternal morbidity and fetal morbidity/mortality.
The guideline stresses the importance of early diagnosis, expeditious laparotomy, and neonatal resuscitation to reduce morbidity and mortality related to uterine rupture.
The guideline also recommends that decisions for induction and augmentation of labour in such situations should be made in consultation with senior obstetric input and after informed discussion with the woman, in recognition of the increased risks. This being an individualised discussion would be outside of the scope of a standard patient information leaflet.
The patient information leaflet Birth after Previous Caesarean2 , while not using the precise term ‘fatal’ in relation to uterine rupture nonetheless states the risks and that stillbirth can be a serious consequence of VBAC.
“Serious risk to your baby such as brain injury or stillbirth is higher than for a planned caesarean section.”
“The scar on your uterus may separate and/or tear (rupture). This can occur in 1 in 200 women. This risk increases by 2 to 3 times if your labour is induced. If there are warning signs of these complications, your baby will be delivered by emergency caesarean section. Serious consequences for you and your baby are rare”.
This RCOG leaflet has been reviewed and updated recently and is due for publication in the very near future.
Counselling for VBAC is never a one-off event. Women should be counselled antenatally, with information revisited in labour because the risk profile is dynamic, particularly where induction or augmentation of labour is being considered. It is the clinical team’s responsibility to ensure that women understand not only the numerical risks but also the potential consequences for mother and baby.
It is also important to note that, under the Core Competency Framework developed by the Maternity Transformation Programme3 and national partners, all maternity units are required to standardise training to enhance safety and consistency in care. Module 3 specifically addresses medical emergencies and multi-professional training, with a requirement that 90% of relevant staff attend annual in-house MDT training (PROMPT) covering at least four maternity emergencies over a three-year period, including uterine rupture, with priorities tailored to local needs. This framework reinforces that the unit has a responsibility to ensure that all staff, including those managing labour, are trained to recognise and respond promptly to emergencies such as uterine rupture. Responsibility therefore extends beyond the individual clinician to the unit’s broader duty to maintain competency and preparedness through mandated training.
Thank you for bringing this to our attention. I hope this is a helpful response to this matter.
Re: Baby Mabel Olivia Williams
Thank you for your Regulation 28 Report to Prevent Future deaths following the inquest into the death of Baby Mabel on 8 September 2025.
The loss of a baby is a devastating tragedy for parents, the wider family, and healthcare professionals involved. We would like to begin by extending our deepest and heartfelt condolences to Mabel’s family for their profound loss.
This response has been developed following input from members of the Royal College of Obstetricians and Gynaecologists (RCOG) Patient Safety Committee and Senior Officers of the College.
We recognise and respect the narrative conclusion from the inquest. The medical cause of Mabel’s death was:
1a) Severe hypoxic ischaemic encephalopathy, 1b) Undiagnosed uterine rupture.
We also recognise the matters of concern as outlined in your letter as follows, When Becky (Mabel’s mother) was advised about VBAC she was referred to internal guidance from the hospital and to the RCOG’s information leaflet “Birth options after previous caesarean section” (published in July 2016). I reviewed the information leaflet and it does not contain any indication that uterine rupture could potentially prove fatal for mother and / or baby. My concern is that prospective parents may rely on this information leaflet to assist them in making informed choices about their birth options, and that if the risk is not identified then other patients like Becky might pursue VBAC in circumstances where – if they had understood the risk better – they would have chosen otherwise.
The purpose of RCOG patient information leaflet is to convey essential information in an accessible format. It aims to support the individualised discussion between the clinician and the woman and their partner and/or other friends and family and is not intended to be a stand-alone resource.
All our patient information leaflets are produced in collaboration with service users and clinicians to try to ensure that they convey information that is accurate, relevant, clear and succinct. The depth of information is agreed after very careful consideration, and with input from service users and clinicians, and highlights that additional conversations with clinicians are needed to help personalise the risks for an individual.
In response to your concerns, this patient information leaflet is based on the RCOG Green-top Guideline No 45 Birth After Previous Caesarean Birth1 (October 2015). The Green-top Guideline states that uterine rupture is a rare but serious complication associated with maternal and perinatal morbidity and mortality:
Women should be informed that the absolute risk of birth-related perinatal death associated with VBAC is extremely low and comparable to the risk for nulliparous women in labour.
Women should be informed of the two-to-three-fold increased risk of uterine rupture and around 1.5- fold increased risk of caesarean birth in induced and/or augmented labour compared with spontaneous VBAC labour.
Approximately 0.5% risk of uterine scar rupture. If occurs, associated with maternal morbidity and fetal morbidity/mortality.
The guideline stresses the importance of early diagnosis, expeditious laparotomy, and neonatal resuscitation to reduce morbidity and mortality related to uterine rupture.
The guideline also recommends that decisions for induction and augmentation of labour in such situations should be made in consultation with senior obstetric input and after informed discussion with the woman, in recognition of the increased risks. This being an individualised discussion would be outside of the scope of a standard patient information leaflet.
The patient information leaflet Birth after Previous Caesarean2 , while not using the precise term ‘fatal’ in relation to uterine rupture nonetheless states the risks and that stillbirth can be a serious consequence of VBAC.
“Serious risk to your baby such as brain injury or stillbirth is higher than for a planned caesarean section.”
“The scar on your uterus may separate and/or tear (rupture). This can occur in 1 in 200 women. This risk increases by 2 to 3 times if your labour is induced. If there are warning signs of these complications, your baby will be delivered by emergency caesarean section. Serious consequences for you and your baby are rare”.
This RCOG leaflet has been reviewed and updated recently and is due for publication in the very near future.
Counselling for VBAC is never a one-off event. Women should be counselled antenatally, with information revisited in labour because the risk profile is dynamic, particularly where induction or augmentation of labour is being considered. It is the clinical team’s responsibility to ensure that women understand not only the numerical risks but also the potential consequences for mother and baby.
It is also important to note that, under the Core Competency Framework developed by the Maternity Transformation Programme3 and national partners, all maternity units are required to standardise training to enhance safety and consistency in care. Module 3 specifically addresses medical emergencies and multi-professional training, with a requirement that 90% of relevant staff attend annual in-house MDT training (PROMPT) covering at least four maternity emergencies over a three-year period, including uterine rupture, with priorities tailored to local needs. This framework reinforces that the unit has a responsibility to ensure that all staff, including those managing labour, are trained to recognise and respond promptly to emergencies such as uterine rupture. Responsibility therefore extends beyond the individual clinician to the unit’s broader duty to maintain competency and preparedness through mandated training.
Thank you for bringing this to our attention. I hope this is a helpful response to this matter.