York – It’s not for women

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AIMS Journal, 2018, Vol 30, No 3

By Emma Ashworth

The York Teaching Hospital NHS Foundation Trust has implemented two homebirth-related guidelines which are putting women, babies and midwives at risk.

The first guideline states that women are not permitted to decline care in their home and still have their midwife remain with them. The wording is, ‘If you arrive at the home of a woman and she refuses to allow you to access her home or to provide care to her, you must explain that you will need to leave and explain this decision to her. You should inform the woman that you will be happy to return to provide care should she want you to do so. The conversation should be fully documented.’ (York Teaching Hospital NHS Foundation Trust, Home Birth Guideline Version No: 9, August 2017 – August 2020, page 7.)

The language in this guideline is ambiguous. It could be interpreted to mean that if the woman does not allow the midwife access to her home, and therefore does not allow the midwife to provide care, the midwife should leave. Another interpretation could be that if a midwife is not allowed into the home OR is allowed into the home but the woman doesn’t accept their offer of checks or interventions, then the midwife should leave. In practice, it is this second interpretation which is being used by York midwives and midwifery managers.

Let’s look at the consequences of this guideline. ‘Care’ could be any intervention or routine check such as vaginal exams, blood pressure checks, auscultation of the baby’s heart, suggestions to change positions, advice to leave the pool or shower or bath. If women decline any of these interventions, they risk the midwife deciding that they need to leave the woman’s home, as per the Trust guideline, abandoning her in labour and leaving her and her baby at risk of not having medical care should it be required. The midwife may be found to be negligent should there be a subsequent adverse outcome for the labouring person or their baby. Alternatively, the woman must accept an intervention which she may not want, which means that she has not freely consented (and therefore consent has not been legally obtained), and this leaves the midwife open to an accusation of assault, a criminal offence.

The second guideline states that if a midwife arrives at a woman’s home and she is found to be 10cm dilated (bearing in mind that if the woman wants the midwife to stay she may be forced to have a vaginal examination), ‘if the second stage does not appear to be progressing well and birth does not appear to be imminent’, the midwife should recommend transfer into the hospital for continuous monitoring of the baby.

In practice, women are being told that if they are found to be 10cm dilated at the point of the midwife’s arrival, but are not yet pushing, they need to transfer in for continuous monitoring. There are a number of problems with this guideline. Firstly, it is clearly the case that assessments of labour progress and how close to birth the woman is are subjective, and usually inaccurate. This guideline increases the risk of women birthing on the way to hospital, with the inherent trauma that that often leads to, as well as the risks to mother and baby. Secondly, the recommendation is being given despite the fact that there is absolutely no evidence to say that continuous monitoring offers long-term health advantages to the mother or baby over intermittent monitoring. In fact, the evidence tells us that continuous monitoring simply increases the caesarean birth rate, causing significant harm to women, subsequent pregnancies and possibly this baby as well.¹

Women have reported that they are scared that the midwives will tell them that they are fully dilated when they’re not, to get them to go into hospital, and other women have discussed their worries of birthing their babies on the way to hospital, or having their labour stall at a critical time, leading to interventions such as artificial oxytocin or caesarean becoming necessary. These are extremely valid concerns – interfering with labour at this critical point can have very serious physiological consequences. Because of this, I have been trying to obtain a copy of the Trust’s risk assessment covering the dangers to women and babies of transfer at this stage, but so far they have declined to share one or to confirm whether one exists.

This is an ongoing issue in York, and AIMS will update its members when there is more information about the situation.

Reference:

1. https://www.cochrane.org/CD006066/PREG_continuous-cardiotocography-ctg-form-electronic-fetal-monitoring-efm-fetal-assessment-during-labour