15 Changes I Want to See in Maternity Care (aka my 15 birth pet peeves)
1. Do not use scan estimates to change a pregnant person’s EDD. A pregnant person is best placed to know when they conceived, and their judgement should always be trusted above a machine’s. This is the first scrape, the first dig, the first undermining of pregnant people’s ownership of their own pregnancy, telling them they are wrong about when their baby is due, and that the machine and the folks in white coats always know better than they do. This is for many the first act of grooming, of gaslighting, that sets the stage for what is to come.
2. Minimise the number of tests performed on healthy pregnant people and their babies. Maternity care has become a barrage of proactive treatment for “just in case” scenarios that are so rare as to be nearly negligible, whilst ignoring the knock-on impact of cascading interventions. Iatragenic (“doctor-caused”) harmful side effects should be the first thing considered, not the last, and the pregnant person’s emotional, psychological and physical wellbeing should be considered just as critical as reducing foetal mortality (arguably more, as the pregnant person is the only “patient” being cared for until after the baby is born). Just because many pregnant people might choose to endanger themselves in favour of their babies-to-be, this does not mean that the medical care of the pregnant people should presume this to be the sole input to decision-making. The rhetoric of “nothing matters but a live baby” is a denial of a pregnant person’s personhood and is an anathema that should be rooted out of every aspect of maternity care.
3. Eliminate the mindset of standardisation from every aspect of maternity care. Pregnancies are not all the same length. Cervixes do not all dilate at the same rate. Different people can manage different levels of blood loss. “Normal” iron levels differ from person to person. Pregnant people are the undisputed experts in their own bodies, and their expertise should be honoured above any notion of “normalcy.” The issue should always be NOT “what is the population norm” but “what is normal for this individual” and clinical decisions should always be made on that basis, and that basis alone.
4. Be honest about when clinical recommendations are being made for that individual’s specific needs, and when they are being made for institutional protection or convenience. Study after study after study has shown that continual foetal monitoring DOES NOT IMPROVE OUTCOMES. It just plain doesn’t. What it does do is provide a very helpful audit trail, so that if something should go wrong, there is a record of when different actions were taken, in response to what information available, that can help a hospital dispute an accusation of malpractice. If this monitoring were without implications for the course of someone’s labour, that might be a perfectly reasonable thing to ask. But studies have also shown that CFM restricts maternal movement, it keeps labouring people out of the “zone” and decreases spontaneity and range of movement, which can have an important negative impact on the delicately balanced choreography of maternal-foetal biomechanics. HCPs (health care professionals) who rely on reading a trace rather than intermittent listening to foetal heart tones are also removing themselves from the intimate physical knowledge of the labouring person’s body and how they are responding, changing, progressing. It allows a detachment which is really unhelpful in detecting real issues and problems in the very early stages. It degrades the quality of care. What it also does is allows HCPs’ attention to turn to writing/inputting notes, overseeing multiple patients and undertaking other tasks unrelated to the birth at hand, thus propping up under-resourced maternity services. Which leads me to
5. Resource maternity services appropriately, so that women can receive one-to-one care throughout pregnancy, labour and birth, and so that there is no temptation to improve labour scheduling efficiency by turning everyone into an induction. Familiarity with a person throughout their pregnancy means that a HCP is far more likely to be able to accurately distinguish between normal and abnormal for that person. The trust developed between them optimises oxytocin flow and makes the whole experience much more fulfilling, for both HCP and birthing parent.
6. Stop inducing people for being “post dates.” Firstly, machine-based dating is mostly wrong, secondly not all pregnancies are the same length, and thirdly the date itself is irrelevant so long as mother, baby and placenta are doing well. Induction shouldn’t even be thought of until after 42 weeks. The induction rate has skyrocketed in recent years, hugely exacerbated by Covid19. It is at epidemic proportions, and it is the logical end of the rhetoric that begins with the dating scan: that women’s bodies are all prone to failure, that the men in the white coats have to rescue a baby from their parent’s faulty body. Rubbish!
7. Stop inducing people for having babies that are “too big” or “too small.” Late pregnancy size scans are incredibly inaccurate, and the size of a baby is not on its own a good predictor of labour or birth complication. Plus in the human species there is an enormous range of perfectly normal and healthy body sizes and weights. This is true of foetuses and babies, too. If a particular problem is suspected, conduct tests for that problem (ie gestational diabetes) but don’t take the proxy measure of estimated weight on its own as a reason to induce, or even worry. Babies and their parent’s bodies are both designed to move, stretch, flex and mould to enable that passage into life, when they are free to move instinctively, without influence or fear.
8. Stop doing routine cervical stretch and sweeps. There is no need for them, they are uncomfortable, they increase the risk of PROM and infection, and they further the harmful paradigm that pregnant people’s bodies are defective and need interference to do their most fundamental task; that the HCPs hold the key to successful birth, not pregnant people and their babies.
9. Stop putting people on a 12- or 24-hour clock when their waters release at term. Instead, teach parents how to monitor their own wellbeing, and trust them to know to report if they are feeling or seeing signs of incipient infection. Eliminate vaginal exams, and wait. With the risk of infection minimised, as long as the baby and their parent are well there is no reason to intervene, even if it is several days before labour begins.
10. Stop doing routine 4-hourly vaginal exams and stop focusing on cervical dilation as the be-all and end-all of labour’s progress. Stop the ridiculous notion that cervical dilation proceeds linearly; stop the notion that there is a “normal” path for labour progress. So long as parent and baby are doing well, there is absolutely no reason for any intervention, no matter how long labour is lasting. If a labouring person feels that something is amiss, listen to them! If they know everything is fine, listen to them! Rediscover patience in maternity care, and cover the damn clocks. Start paying attention to what the labouring parent is telling you about their own and their baby’s wellbeing, and their wishes for their care.
11. The same goes for pushing. 10cm dilation is not in itself a sign to begin pushing; the urge to push is the sign to begin pushing, and there can be a substantial gap between 10cm dilation and the urge to push, depending on the baby's journey through the pelvis. So long as everyone is fine, let it take the time it takes. Let labouring parents move and push as and how they instinctively wish. Let it take the time it takes. Don’t be in such a rush to intervene.
12. Don’t cut the cord, preferably until after the placenta is born, but at the very least not until it is completely and utterly white. If resuscitation activities need to be carried out, do them with the cord still attached on the birthing parent’s belly; do not take a poorly baby away from their parent ever except as a complete last resort. A parent’s body is the best thermoregulator, breathing regulation and comfort measure there is. Babies, ESPECIALLY poorly babies, need their full complement of blood, and up to 30% will be in the cord at birth.
13. In the absence of PPH (post partum haemorrhage), have patience for the delivery of the placenta, and just leave parents alone with their newborns for the first hour at the very least. The rush of oxytocin generated by the three of them interacting uninterrupted is the best way to encourage a placenta to be born naturally. Just leave them alone and let them enjoy each other; they will never have this moment again. It’s not your show, it’s theirs; be respectful of their space.
14. Stop prescribing “just in case” antibiotics to parents and babies. The importance of the gut microbiome to the development and establishment of digestion, of the immune system, of a myriad other biological functions cannot be overstated, and interfering with unnecessary antibiotics can have huge and lifelong impacts. If a need for antibiotics is expected, test and then act, not the other way around.
15. Supply people who want to breast or chest feed with informed, dedicated, patient, one-to-one in-person support, for as long as it takes. The UK has THE WORST breastfeeding rate in the world, despite the fact that more than 80% of birthing people say that they would like to breast or chest feed. This has so many knock on effects, for babies, for parents, for society. Successful feeding can be such a huge boost to parental confidence and wellbeing, as well as clearly being medically optimal for babies. Nothing substitutes for a knowledgable person sitting with the new parent -- for hours as necessary -- supporting them to position, latch, learn feeding cues, monitor signs of milk transfer, understand feeding patterns, and troubleshoot problems. Resourcing this activity for newborns would save the NHS millions in preventing later problems (see 5 above).
These are simple, mostly cost-neutral, evidenced-based, and immediate things (well maybe aside from the funding) that could be achieved right now, that would be so hugely helpful to birthing parents and their babies.