Many expectant mother dread the prospect of a surgical delivery.  Medical staff also prefer natural deliveries.  We hope that surgical deliveries are reserved for emergency situation and hopefully completed where necessary to avoid undue risk to mothers and their babies.  

To complete a surgical delivery where natural delivery has taken place is very rare.  

What observations were being made at the time the procedure was progressed to incision?  The physical position adopted by a mother for a natural delivery is very different from that when surgery is needed. 

 We can only speculate as to the what has occurred in this case but this highlights the importance of good observation when delivering clinical treatment.  It also begs the question of who was making observations?