I asked Chatgpt my first question yesterday. Because I thought I was getting a bit institutionalised in my old age. See, I used to be a home birth midwife. Now I’m a hospital one. And much as I love a water birth on our Midwifery Led Unit, I’m just as likely to love a good epidural. Is this bad?

Ok, so here’s the thing. I loved being a homebirth midwife. It wasn’t just actual births though, it was the continuity of care that I could give, seeing most women from their first appointment (unhurried, in their homes) to their last post-natal appointment up to 28 days after the birth. It was my whole life, my entire identity, I didn’t have time for much else, but I loved it.  Look, I was young so I’m looking back with rose-tinted glasses as one is wont to do half a lifetime later. I realise it wasn’t perfect, I mean, we were never more than a hair’s breadth away from being burnt out because it was exhausting. We spent half our lives on-call, never knowing if we were coming or going, unable to make any plans. We often worked 24 hours straight, were regularly rostered for 10 days stretches. Our South London patch was extensive and we drove miles, without satnav. But I had fabulous colleagues that had my back, and the births, wherever they took place, were always very special. But even back then, we knew when to transfer in. Babies are resilient, we knew that, but only up to a point, and we’d be in hospital long before our babies reached that point.

In midwifery, it’s always a delicate balance between maternal health and autonomy versus babies’ health. In the UK, we prioritise the mother if pregnancy puts her life in jeopardy no matter how far along that pregnancy is. If it’s ectopic, it’s a no brainer: that bundle of directionally challenged cells (should have gone to the uterus, stopped waaay short) are going to destroy the mother if left unchecked. If her waters break too early, we’ll do what we can to prolong the pregnancy with antibiotics to prevent infection from setting in order to give the baby a chance, but bottom line, if that baby’s mother doesn’t survive, neither does the baby. Same with pre-eclampsia: if the baby accidentally causes the mother’s death from a stroke, it won’t make it either. Of course, when we end a pregnancy early (but after 24 weeks) we will endeavour to keep the baby alive thanks to the amazing neonatal intensive care units, thereby saving both lives. Sometimes it’s less cut and dry, and mothers are faced with difficult choices but that’s the key: faced with unwelcome news about either the mother’s or the baby’s prognosis, they have a choice regarding how to proceed. Look, no-one wants to have to make these choices, they suck. But the alternative is much worse. 

Even when everything goes smoothly, mother and baby live in uneasy equilibrium. The baby’s placenta causes all sorts of mischief, from diabetes to high blood pressure. The mother’s immune system is all but taken out to sustain the pregnancy because it would otherwise destroy the baby.

When the mother-baby duo make it to term with minimal problems, or at least none that we couldn’t deal with,  we now have to deal with the baby’s exit. Not gonna lie, this may be a natural process, but it ain’t easy. It isn’t easy for those who have the most straightforward births, and without help, it is near-impossible for others. Wherever one finds oneself on that spectrum, close supervision is advisable. I’m biased, obviously, because I’m a midwife so I’m hardly going to underplay my role as chief pregnancy and childbirth supervisor! We’re there to see problems before they are a big deal, and course-correct in a timely manner. There’s lots of disasters that we quietly avert simply by giving good, science-based advice, or noticing when something isn’t quite right and making sure a woman is seen by the obstetrician. Prevention is our MO. We don’t mind being proved wrong if, after investigation, everything is in fact, ok. It usually is, but that doesn’t stop us from referring the next woman for who triggers our potential-abnormality-radar. But we also have to know when to wait. When to trust women to auto-correct from minor variation. And we do; we are brilliant at watchful waiting. Because pathologising a minor blip too quickly can result in unnecessary interventions which are best avoided because they are stressful, time consuming and, yes, expensive. [We are so lucky we don’t actually care about the cost thanks to our wonderful NHS, but still…] So, we can deal with stress, time and cost. But the main solution to pregnancy problems is to evict the baby. Thus, if we worry excessively and overdiagnose  healthy women, this can lead to more untimely inductions of labour which nobody wants. That’s not to say it isn’t the wisest course of action: it very often is. We have to strike a balance, giving the baby as much tummy time as possible while recognising that too much tummy time can be lethal. It’s not easy. To complicate things further, mothers are older, heavier, and living with more chronic conditions than ever before and we do need to keep this in mind when looking after them. At risk of repeating myself from previous posts, and with apologies to my loyal readers who know this already: if the baby has stopped growing, if the baby is too chubby, if there’s infection, or blood pressure issues or diabetes, those babies do need to be born sooner rather than later. It’s always in both the mother’s and the baby’s interest. You don’t want to give birth to a hephalump. That’s gonna hurt, or get stuck, or both. You don’t want to wait to get full-on eclampsia. You do not want to go into sepsis. You can’t wait to see if your teeny weeny baby will subsist until its official due date.

So my question to Chatgpt was the following: how often do we cause problems by acting too soon when problems arise. I worry about becoming institutionalised, having spent so many years on the labour ward, away from the home births. You see, I don’t think that inductions are to be avoided at all costs even though I understand why it’s no-one’s first choice for birth. Plus I’ve long suspected that as a first time mum going into spontaneous labour, you’re  as likely to have a c/s or an instrumental birth than if you were induced. ChatGPT confirms my hunch:”Best-quality evidence (RCTs and meta-analyses):
✅ Inducing labour at *41 weeks in low-risk first-time mothers does not appear to significantly increase the risk of instrumental (forceps/vacuum) delivery compared with expectant management to 42 weeks.
✅ Caesarean rates also remain similar between the two strategies in many trials.”

Induction at 41+ weeks, but before 42 weeks can prevent still birth, we know that, so on balance, it makes sense to offer this. You are not obliged to take us up on our offer, but we are keen to let you know why we do.

Giving birth to our Firstborn is just hard. We are sorry about that too. But we think our firstborns are pretty important. It’d be wrong to treat them as a practice run, hoping for the best, but maybe better luck next time… [Full disclosure: I’m a firstborn, so I have skin in this game!]

Added to which, we’ve all read the awful enquiries into avoidable maternity deaths. So we know that the lessons, time and again, are that we should have acted sooner. We should have delivered that baby earlier.

A big part of my job is to convince women that we are actually acting in their best interests when we recommend inductions. But we are met with resistance, like we are denying them the right to an unassisted drug-free birth. And maybe we are. Sort of… because it cannot be denied that an induction can be long and stressful, and tiring. Being tired and stressed does nothing to enhance one’s ability to cope with pain. And pain is, unfortunately, an unavoidable part of labour. No pain equals no contractions equals no baby. In spontaneous early labour, you can hang out at home where you hopefully enjoy peace, privacy, your own food whenever you fancy it, your own bathroom… there are no deadlines. It’s still labour, it still hurts, but you might find ways to cope. When in hospital, the bed is less comfy, it’s often noisy, the food is decent but arrives when you don’t want it. You are quite often clock watching for the next unwanted intervention. You are exhausted and beyond stressed. It doesn’t help that you’ve been panic-googling. We know that this isn’t conducive to the release of natural oxytocin which you need for labour to get going. We are sorry about that. Genuinely. And we do try to help in any way we can, by getting you to be as active as possible (even going for a walk to the local park), by giving you plenty of reassurance, keeping lighting low, offering simple anagesia, encouraging use of birth balls, getting you in the bath or having a long shower, or watching something familiar and/or predictable on Netflix… but we sadly cannot predict when this baby will make its grand entrance, or how. This uncertainty is very unsettling, we know that, and we are sorry. We’d like you to know that we’ll take care of you. We know you’re not keen, but might we recommend a lovely epidural if things get overwhelming? We’d also like to remind you that your unwanted induction of labour isn’t because you’ve done something wrong, nor has the baby. We know that, had we done nothing, you and baby would probably be ok BUT, and this is a big but: we ain’t keen on playing Russian roulette with your baby. It’s your perfect baby for whom you’ve been following all the pregnancy rules (including some that came as news to us) to keep it safe and well. You’ve attended all the checks and scans because you knew that good antenatal care saves lives. You’ve put up with pain and discomfort, sometimes without even taking paracetamol just in case (you absolutely can take paracetamol). You’ve made a huge effort with your diet and exercise. You haven’t touched a drop. So you absolutely deserve that candlelit waterbirth. But something’s come up and now you’re in hospital having an induction that everyone (wrongly) warned you against. It’s hard to swallow. We understand that too. We are sorry.  But, as I always say, what is the point of all our checks if we ignore inconvenient results?

We want you to have your natural birth. The obstetricians will get a break and the NHS will save money. You’ll recover faster. As your midwife, I’ll be there for you no matter how you deliver, but I can’t lie, I’m absolutely delighted when I get to do the catching. Just not at your baby’s expense. Or yours. 

Perhaps this means that I am institutionalised.

I’m not sorry.