Better Births for all - there's no such thing as "normal"

The Royal College of Midwives (RCM), the midwifery trade union, have confirmed that they are bringing to an end their 12-year-long campaign to promote “normal” births. In a statement dated 14^th August, the RCM confirmed that following its decision to discontinue its Normal Birth Campaign as part of a Better Births initiative which seeks to improve care for all women, including those with medical and obstetric complications, “out of date” references to the campaign were removed from its website in May of this year.

Midwives will now be required to use less value-laden or pejorative language in relation to the different methods of giving birth. Spontaneous vaginal delivery should properly be called “physiological” birth, a term which describes the unassisted method of childbirth without the implied assumption that midwife or mother have failed if the mother requires medical intervention, such as epidural anaesthesia, instrumental delivery with forceps or a caesarean section.

The Nursing and Midwifery Council (NMC) is the regulatory body for midwives in the UK. The introduction to the NMC’s Standards of Competence for Registered Midwives says, “Registered midwives will be expected to understand, promote and facilitate normal childbirth and identify complications that may arise in women and babies. They will know when to call for assistance and implement emergency measures, often in conjunction with other health professionals. It is important for midwives to promote health and wellbeing and to provide unbiased information and communicate effectively with a range of women and their families.” They have a dual obligation to facilitate “normal” childbirth whilst identifying complications and calling for medical assistance when needed. Over emphasis on the former to the extent that they fail in the latter can have devastating consequences for both mother and child.

Whether in a home or hospital setting, “natural”, “normal” or “physiological” childbirth is the domain of the midwife. However, unassisted, unmedicated spontaneous vaginal delivery is not appropriate or possible for all. Obstetric intervention might be required for physiological reasons, e.g where the baby’s head is expected to be disproportionately big for the mother’s pelvis, or as a result of other health risks, e.g. where the mother has had a previous caesarean section or complications during pregnancy and is at risk of uterine rupture, eclampsia or other devastating injury. Many of these risks can be identified before the mother goes into labour, allowing an appropriate means of delivery to be planned and discussed with the mother, and carried out with adequate midwifery and medical support for the safety and wellbeing of both mother and baby.

The real dangers inherent in a “normal birth” campaign come to light where unforeseen risks or complications arise during the labour and delivery. In such circumstances, causes for concern, such as abnormalities in the baby’s heart-rate, and emergencies, such as cord compression and abruption, require midwives to act quickly, acknowledging that the patient requires medical review which might lead to intervention to expedite a safe delivery. In units where there is poor communication and in some cases a competitive power play between the midwives striving for a “normal birth” and the medical team to whom they are reluctant to hand over control, delays in accepting that medical review is required seriously put the health of both mother and baby at risk. In these challenging situations, the midwife’s recognition of her vital role in recognising potential problems and calling for assistance from obstetricians, anaesthetists, and paediatricians is critical. Prompt action in this area is as much a life-giving service as delivering the baby by natural means.

In 2015, The Report of the Morecambe Bay Investigation attributed the avoidable deaths of 16 babies and three mothers at Furness General Hospital between 2004 and 2013 to “a lethal mix” of deficiencies which included, extremely poor working relationships between obstetricians, paediatricians and midwives at the “dysfunctional” maternity unit, and “a growing move amongst midwives to pursue normal childbirth at any cost”. Several of the midwives at the heart of the Morecambe Bay problem have been investigated by the NMC but the Secretary of State for Health, Jeremy Hunt, has recently ordered an investigation into the NMC’s deficient handling of those complaints.

The Royal College of Midwives has now commissioned a team at Nottingham University, led by Professor Helen Spiby, to update the RCM’s Guidelines for Midwifery Care in Labour. The review of the guidelines will be evidence-based and aims to support midwives in providing safe and effective care to all women.

As specialists in birth injury claims of maximum severity, Boyes Turner welcome the RCM’s long overdue change in approach. Over more than 20 years we have acted for severely disabled clients whose brain injury and consequent disability were caused by delay or failure on the part of midwives to call for timely medical review and intervention.

In one recent case we secured an admission of liability for a five year old girl with severe dyskinetic cerebral palsy. Her injury was caused by an acute period of hypoxia (lack of oxygen) in the minutes leading up to her delivery, which was delayed by negligent midwifery care. Throughout the mother’s pregnancy, labour and delivery, the need for obstetric and paediatric involvement was ignored, despite abnormalities in the fetal growth, a history of bleeding, and heart-rate abnormalities indicative of a near terminal lack of oxygen. With appropriate medical intervention at any stage of the pregnancy, labour and delivery, our client’s severe brain injury would have been avoided.