Please, don’t be mad…

Look: when your uber driver sticks to the speed limit even when you have a plane to catch, he’s respecting the law. Sure, your plane is important. So is the safety of other road users. As is his livelihood. He might take risks for you if he knows where all the speed cameras are, if he knows the back roads, if he’s an experienced driver and if you can convince him that your tardiness was due to exceptionally unlucky circumstances. If he does get caught speeding, he’ll have to endure the legal consequences.

Midwives have a bit more leeway. We have our guidelines which we are trained to adhere to, but they are not the law. They really do help us plan and deliver quality care though. Otherwise everyone one of us (midwives and obstetricians) would have to sift through all the research about everything all the time and it would be chaos. Instead, others have done that work. They have read and summarised all the available decent evidence, and turned it into a comprehensive set of instructions for any given situation. Everyone has access to it, and this allows us all to sing from the same hymn sheet. We might not all agree with everything in it, and we are fully aware that our clients do not always agree with it, but it’s a common starting point for conversations based on proper evidence.

That’s not to say the evidence gives us all  right answers all the time. Far from it. Being guided by scientific evidence means taking into account what works on a population level. The shift in favour of that population thanks to the intervention in question is real but it is often small. It may be small, but statistical analysis indicates that these small benefits are not random, thus, if the study were repeated you’d expect to get the same results. Bottom line: if we follow the evidence, we will, overall, improve outcomes. So it makes sense to do just that.

In midwifery the stakes are high when we get things wrong. We’ve come a long way to improve outcomes, but we cannot rest on our laurels. Every death is a tragedy and it’s absolutely reasonable to treat them all as preventable, and to work hard to prevent them all. We still have a way to go.

Loyal reader, you’ll forgive me for sounding like a broken record but pregnancy is really bad for women. Pregnancy puts pressure on the mother’s heart and lungs due to extra circulating blood volume and carrying (unavoidable, necessary) extra weight; it makes her blood sticky and liable to clot thereby blocking vital blood vessels; it might cause her blood pressure to rise, putting her fragile capillaries at risk of rupture; it can completely deregulate her ability to metabolise sugar, causing diabetes; it changes her urethral anatomy, causing urine infections that can put her kidneys at risk and cause premature labour; it causes serious anaemia at the exact time she’s expected to lose roughly a pint of the red stuff; it causes terrible nausea and vomiting just when her own reserves of nutrients are being guzzled by her insatiable baby; and it seriously impairs sleep so that there’s zero chances of getting to labour well rested.

Don’t even get me started on the risks of labour when, even if all goes well, both mother and baby are sorely tested.  Without the right care, one or both can very easily die. It’s easy to forget that giving birth (the so-called most natural thing in the world) in many parts of the world is still crazy dangerous. Where it’s less dangerous, it’s because of careful monitoring and judicious evidence-based interventions. Sometimes, not gonna lie, we do seem to go a wee bit overboard with the interventions, and I’m very aware that these can seem brutal. It’s unfortunate that we only have 2 ways to rescue a seriously distressed baby: one involves medieval-looking instruments and the other involves a rather large surgical incision through several layers. Worse: if we don’t rescue the baby in time, it can die but it’ll still need to be delivered. Preferably before it causes the mother a lethal infection. So please forgive our seemingly excessive caution, but remember, your baby isn’t a game to us.  We are not sorry about that.

Years of trial and error (maybe not enough scientific trials and rather too many errors) and we are getting better at mitigating these risks. We’re getting better at detecting symptoms long before they cause problems. Through careful monitoring of pregnant women at every antenatal appointment, we gather physical evidence of well-being and when things get a little bit borderline, we don’t have to guess what we ought to do next. So if her blood pressure is raised, there’s a cut off point at which we refer to the blood pressure clinic. Prior to guidelines as to what constituted borderline blood pressure, each midwife might have had her own ideas about how high a woman’s pressure should be before you considered sending her to the obstetrician,  and the obstetrician would have her own views on when it might be appropriate to give medication. It wasn’t standardised. I might have a woman whose blood pressure was a little over what I felt comfortable with, but it was her usual reading. Should I be concerned? Would the obstetrician take it seriously if I sent her in? Or would they  resent my excessive caution and make that woman feel like a waste of time? No midwife wants that. Thing is, without guidelines, it’s all guesswork. It’s bad enough guessing when to worry; it’s even worse worrying about offending the doctors. Of course you could argue we are trained to discern the borderline-but -probably-ok from the borderline and about to develop full-on pre-eclampsia, but the truth is we can never be sure. Sometimes there are a few other symptoms which makes the decision straightforward (although at that point some might argue we’ve left it a little late) but more often than not, the woman is absolutely fine until she’s frothing at the mouth. You’d be surprised how common that was when I first qualified. Women who feel absolutely fine resent being sent to the obstetrician, and are properly peeved when that obstetrician then implies that she’s wasting his time and that her midwife should not have sent her. Now everyone is miserable. And of course, this woman no longer trusts us, and may not come for her next appointment, where we might have noted a significant rise in her blood pressure. Thus, the little things can trigger big but totally preventable problems. With the guidelines,  there are fewer misunderstandings. Everyone knows exactly what blood pressure triggers a referral. This doesn’t mean that my borderline patient is forced to see the obstetrician, and it is perfectly feasible for us to come up with a plan for me to see her again the next day, but we will have had that discussion based on the guidelines. Which are based on evidence.

However, I cannot emphasise enough, guidelines are a starting point for conversations about care, not the law. We are, however, duty-bound to inform you about our guidelines. This isn’t to annoy you. It isn’t to scare you. We aren’t trying to coerce you into accepting treatment that you are uncomfortable with. It’s just a way of telling you what we recommend based on what we know about you and the evidence we have painstakingly gleaned. Here’s the thing: we know a great deal about you. And we’d prefer you not to base all your preferences on what Tiktok suggests. Even if your fave influencer is really well informed, they simply don’t know you. Your midwife has, at her fingertips, all your medical history, your allergies, your obstetrics history, your surgical history; she has all the current pregnancy scans, blood results, previous blood pressure readings, and any encouters with the physio, the obstetrician, the psychologist… this means we can devise a made-to-measure plan which will make your birth as safe as possible while taking into account your preferences.

You come to your antenatal appointments and we hope to give you a clean bill of health because you’ve done everything right, we know that. But pregnancy is tough and sometimes you’re going to need a bit of assistance. This isn’t failure on your part, it’s biology. Today, we know how to nudge biology back into a more favorable trajectory. This is awesome! We control your blood pressure, you can have your waterbirth.

Sometimes it’s less awesome, and we have to recommend care that you find rather less palatable than some blood pressure tablets.  We are painfully aware that you don’t really want to hear about it. But seriously, what’s the point of attending all your scans and appointments, designed to pick up problems, if you’re going to vigorously refuse the care we recommend when these problems are diagnosed. You can refuse, but we still have to tell you. That’s what informed choice means. We know you aren’t just a statistic. We know you are probably right when you say you’re going to be just fine without the extra help. We know that when your risk of something bad happening doubles, it’s probably gone from 0.05% to 0.1%, which is still a very tiny risk. But when an organisation is looking after thousands of women, that increase in risk can make a discernable difference to its statistics, and we know you are looking at these stats when you are choosing who to trust your life to.

It also helps if you remember we do care. We know what you’ve heard about maternity services. We really are sorry about that.

[Although a lot of these problems would disappear if NHS staff were treated as we are expected to treat our patients… Imagine if we were genuinely fully staffed (not counting those off sick or on maternity leave) with the correct skill mix (could we talk about staff retention please, try to stop losing experienced staff to burnout due to crazy shifts and unrealistic expectations) meaningfully trained and properly updated, fully-rested, never overwhelmed, better paid employees… Seriously, imagine that!]

It also helps to remember that every midwife is legally obliged to maintain standards which allow her to remain on the professional register. Thus, she cannot go too far off script. Her livelihood depends on it, never mind your safety. This affects the risks she is prepared to take. Remember also that your midwife has certainly witnessed tragedies that you cannot imagine. Thus she knows that these things happen. She’d do anything to keep you from experiencing such a tragedy. Please don’t judge her. Everyone’s attitude to risk is different, and where you see your right to choose, she may see her registration (that she has worked unbelievably hard for) going down the plughole. Both things can be true!

I’m a cyclist. I was a homebirth midwife. I’ve been qualified for two and a half decades. I was a nurse before that. I’m probably more comfortable with risk than others. Or, to put it another way: hard won, guideline-free experience has taught me roughly where the limits are for each individual mother. And yet, I much prefer guidelines. Guessing is like playing poker with your life at stake. Not cool. Totally exhausting. Potentially disastrous. I’m glad I no longer have to rely on Lady Luck.