Turf war on the maternity ward: As doctors and midwives clash over the best way to give birth, how babies are being put at risk 

  • Laura Wood, 26, from Southampton, was planning a home birth in 2014 
  • But she was one of up to eight in every 100 women whose babies don't turn
  • She didn't know about her baby's position until after her son was delivered
  • Laura was examined by a community midwife - yet left to labour at home

Laura Wood, a 26-year-old PhD student, was confident that the home birth she was planning in February 2014 would be a positive experience. 'I was young and healthy, with a strong support network,' she says.

As well as her husband Jon by her side, she would have a doula (a labour assistant) and a community midwife who could contact the hospital should anything go wrong.

But there was one detail that would upset her plans - for what Laura didn't anticipate was that as her baby began to descend during labour, he would end up facing the wrong way, with his back against her spine.

Laura Wood, 26, from Southampton, pictured with son Arthur, attempted a home birth

Laura Wood, 26, from Southampton, pictured with son Arthur, attempted a home birth

It is a common problem, affecting one in three women at the onset of labour. Most 'posterior' babies turn naturally as the labour proceeds but Laura was one of up to eight in every 100 women whose babies don't turn - their heads take up more space and the shoulders are more likely to get stuck so that often the solution is forceps or a caesarean.

Laura didn't know about her baby's position until after her son was delivered, when she saw it in her notes but as she says: 'In fact the signs were there from soon after the onset of labour, with my regular frequent contractions without being dilated. Had we known, I think we would have requested a Caesarean earlier on.'

Instead, over four days, Laura was examined several times by the community midwife but left to labour at home. Her husband Jon recalls a confusing and frightening time: 'Laura was screaming and clearly in agony but all I was told was that she was barely dilated and so there was nothing much to be done.'

In the end, it was he who decided she had to go to hospital. There another midwife examined her and incorrectly noted that her baby was in the 'ideal position for birth'.

'For her, I was just another woman having a long birth,' says Laura. She was given an oxytocin drip to speed up labour and then began to push involuntarily, even though her cervix was still not fully dilated. Eight hours after she was admitted, her heart rate sped up to 200 beats per minute (instead of 60 to 100) and her labour became a medical emergency.

'Laura was screaming and clearly in agony but all I was told was that she was barely dilated and so there was nothing much to be done,' recalls husband Jon, who decided she had to go to hospital

'Laura was screaming and clearly in agony but all I was told was that she was barely dilated and so there was nothing much to be done,' recalls husband Jon, who decided she had to go to hospital

Laura was rushed to theatre where a forceps delivery was attempted but failed and she finally had an emergency Caesarean during which the incision tore and she suffered a severe haemorrhage.

Today, two years on, Laura feels that a key factor in her shocking experience was that the midwives appeared to believe they could manage dangerous symptoms when in fact she needed medical intervention.

'Normal' birth seen as better, whatever the cost

While most babies in the UK are born safe and healthy, Laura's story reflects a major problem today: substandard maternity care causing avoidable damage, even death, notably when a 'low risk' pregnancy suddenly becomes an emergency.

In these circumstances, women can be caught in the crossfire of 'a turf war' between midwives and obstetricians over which is best - natural childbirth or medicalised labour.

It is a problem identified by the National Maternity Review published three weeks ago which warned of variations in the safety of maternity care as health staff 'too often fail to work well together, especially across professional divides'.

At its extreme, midwives have refused to refer women to clinical specialists in the same hospital. This is what occurred at the maternity unit at Furness General Hospital in Morecambe Bay, Cumbria where 11 babies and a mother died between 2004 and 2013, due to a 'lethal mix' of failures, an inquiry concluded last year.

The report said these failures included 'a growing move among midwives to pursue normal childbirth at any cost'.

At the hospital a midwife examined Laura and said her baby was in the 'ideal position for birth'

At the hospital a midwife examined Laura and said her baby was in the 'ideal position for birth'

When midwives and doctors won't speak

At the heart of these tragedies were 'extremely poor working relationships between midwives and obstetricians'.

The report said: 'It was a "them and us" culture, with repeated instances of failure to communicate important clinical information about patients.'

Liza Brady's son Alex was stillborn when he was delivered at Furness in 2008 with his umbilical cord wrapped tightly round his neck after midwives repeatedly refused her request for a caesarean during her 13-hour labour.

'This was even though the baby was large and a consultant obstetrician had suggested I might need a Caesarean,' she told Good Health.

'But the midwife was on a mission to deliver Alex naturally at any cost; at one point she told another midwife I'd requested not to have an episiotomy [a surgical cut to help delivery] which was untrue. At another point, a doctor who was coming on duty offered to help but he was shooed away by the midwives who said he wasn't needed.'

Now there are fears that a policy of natural childbirth outside hospital is gaining official backing. In December 2014, the National Institute for Health and Care Excellence (NICE) issued new guidelines stating: 'Midwife-led care is safest for women with straightforward pregnancies, with home births as safe as those in a midwife-led unit attached to a hospital.'

These guidelines are echoed by last month's National Maternity Review, which recommended that all pregnant women be given a £3,000 'birth budget' to spend on 'personal' midwives.

The policy is based on research published in the BMJ in 2011 that for first babies, home births carry a slightly higher risk of harm but the risk is negligible for second or third babies, whether the mother has her child in an NHS hospital, a midwife-led unit or at home.

At the same time, women who have their baby in hospital are significantly more likely to have a potentially risky intervention: an induction, an episiotomy, forceps or ventouse or a Caesarean.

Told to 'wait and see' when medical help is needed

There is concern that these official recommendations are a sign the pendulum has swung too far in favour of women having natural births while supervised only by midwives.

This worries James Titcombe whose son, Joshua, died of sepsis at nine days old at Furness General in 2008 when midwives failed to spot the infection. James campaigned for eight years to get those responsible held to account, a campaign that led to the National Maternity Review.

Now there are fears that a policy of natural childbirth outside hospital is gaining official backing

Now there are fears that a policy of natural childbirth outside hospital is gaining official backing

Last September, however, James resigned from the Review because, he said, 'the balance' of the investigation 'is weighted towards the professional midwifery voice'. The change to bring more women under the exclusive care of midwives is not backed by the evidence, says James, now national adviser on patient safety for the Care Quality Commission, although here speaking in a personal capacity.

'We hear reports of women in labour having their concerns dismissed, of being told to "wait and see" by their midwives, rather than recognising signs that there are problems and referring at an early stage to doctors. I still see midwifery leaders describing the role of a midwife as being to protect "normal" births.'

This argument has lasted 40 years

The turf war between midwives and doctors began in the Seventies when hospital births reached their peak.

It was a time when such technologies as electronic foetal monitoring to track the baby's heart rate during labour, a synthetic version of the 'birth hormone', oxytocin, to induce or speed up labour, as well as the epidural, became widely available - all requiring admission to an obstetric ward.

We've had our fair share of health problems and it's been harder than I could have imagined

An unforeseen consequence was that midwives, then the undisputed experts of 'normal' (vaginal) birth, were 'disempowered', according to leading London obstetrician and natural birth campaigner, Professor Wendy Savage.

'In the Fifties, we were taught by midwives who were hugely respected by consultant obstetricians,' says Professor Savage, who is now retired.

'They were largely autonomous in managing healthy women, with obstetricians experts only in abnormal births. Then everything changed; doctors and women started to worry about something going wrong.

'The whole approach to normal birth became negative: women needed to be protected from harm and for some obstetricians, that meant removing women from the care of autonomous midwives.'

Despite attempts to restore midwives' autonomy, hospital birth remains the norm. Women today can choose between birth at home, in a free-standing midwife-led unit or in hospital - but nine out of ten choose the hospital.

Are women pressured into hospital births?

There, midwives say, women are exposed to unnecessary, risky interventions. They are five times more likely to have a Caesarean, carrying the risk of complications including infection and bleeding.

Against that, however, most obstetricians take the view that even low risk labour is unpredictable and a safe birth is one that takes place where a woman can be monitored and offered the option of a forceps or Caesarean.

Six weeks after Arthur was born, Laura was admitted to a psychiatric mother and baby unit after a breakdown

Six weeks after Arthur was born, Laura was admitted to a psychiatric mother and baby unit after a breakdown

For some obstetricians, the only truly low-risk birth is one where the baby has already been delivered safely, says Linda Levison, head of clinical negligence at the London law firm, Pattinson & Brewer

'I understand that view, as every day I see the consequences of those rare cases where a mother is terribly damaged or her baby has died because she has chosen to have a baby outside a fully-equipped hospital.'

Last year the High Court awarded £4.3 million and annual payments of £210,000 to one of her clients, a child, now 13, born in a midwifery unit which was a 40-minute drive from the hospital. 'The midwives didn't call an ambulance until the baby had suffered a major collapse and cardiac arrest, leaving her with cerebral palsy with severe disability ' says Ms Levison.

'If this baby had been born in hospital, she would probably now have little or no disability. Women should be made aware that in the unlikely event of a serious complication, the minutes needed for transfer to hospital can make all the difference between serious brain injury and an uninjured child.'

Mother punished for choosing water birth

whichever choice women make, they risk being caught in the middle of the turf war.

Susan Wilson, 32, a photographer and mother of two from Reading, believes she was punished by a doctor for choosing a natural birth when she transferred to hospital in May 2012 after several days of labour without becoming dilated.

She is now an advocate for mental health and maternity care but has nightmares and flashbacks

She is now an advocate for mental health and maternity care but has nightmares and flashbacks

'I was certain that I needed a Caesarean and the midwife who examined me agreed but the consultant obstetrician said: "You wanted a water birth, now you're asking for a Caesarean. That's not going to happen."

'The midwives stood behind the obstetrician as she was saying this, looking at me and telling me with their eyes that they were so sorry but they weren't going to speak up,' says Susan. 'It makes me cry when I think of that.'

After several more hours of labour she needed an emergency Caesarean under general anaesthetic. 'Fortunately my baby was safe but it infuriates me that staff back-biting was more important than my safety,' she recalls.

'No right or wrong way of having a baby'

Laura Wood says the problem is maternity health professionals tend to believe there is a right and wrong way of having a baby: 'Yes, there are things which are wise to do but health professionals should not suggest that there is a formula to guarantee a positive experience.'

French obstetrician, Dr Michel Odent, who is widely seen as the founding father of natural childbirth agrees: 'It's often said that I promote natural childbirth - but I would never promote anything to a pregnant woman and nor should anyone.'

Rather than any sort of fixed expectation, 'we should talk instead about "easy, unmedicated" births - that occur when

both women and health professionals let go of fixed expectations, whether they are at home, in a midwife-led unit or a hospital'.

Safe birth is when both sides work together

Joint training sessions for all those involved in the care of women giving birth, at home or in hospital, at least one day a year, make a difference to safety.

Since 2000, Southmead Hospital in Bristol has used one such training package developed by the charity the PROMPT Maternity Foundation designed to improve the response to emergencies in any setting.

'What's changed is that we don't see ourselves as midwives or doctors offering different services to patients, we're a single team that trains together year in, year out to provide ever safer healthcare to our mothers and babies,' says Dr Jo Crofts, a consultant obstetrician. The results have been significant: cases of babies born with low oxygen (a cause of brain damage) have halved, with significantly fewer cases of nerve damage from shoulder dystocia, where a baby's shoulder gets stuck.

There has also been a 91 per cent reduction in litigation.

Such a scheme might have made a difference to Laura Wood. Six weeks after her son Arthur was born, she was admitted to a psychiatric mother and baby unit after a breakdown.

She is now an advocate for mental health and maternity care but two years on regularly has nightmares and flashbacks. 'We've had our fair share of health problems and it's been harder than I could have imagined, but Arthur is healthy and running around and I am thankful,' she says.

Laura Wood's blog: keepingiteclectic.co.uk 

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