It's virtually impossible not to be labelled as high risk these days, but what does it ACTUALLY mean? I chat to midwife Daisy Kelly about the high risk label, why context and personalised care is so important, and what you can do if you're given the label of high risk. We talk rights, advocacy, delving in to statistics and making sense of chance and risk, and talk in more depth about specific situations such as PPH, big babies and other common "high risk" labels.
0:04
Welcome to the Better Birth Podcast.
My name's Erin and I'm a hypnobirthing and antenatal instructor, birth activist and all round birth geek.
In this podcast I chat to experts in the field of pregnancy and birth, debunking myths around birth, diving into the research around maternity care, and exploring what is it that means you're more likely to have a positive birthing experience.
0:28
If you enjoyed this podcast, do feel free to buy me a coffee and fund my caffeine habits.
Link to my Buy me a Coffee page is in the podcast info.
Enjoy this episode.
0:52
Welcome to the Better Birth Podcast.
Today I have the pleasure of speaking to the very wonderful midwife, Daisy Kelly, who I have worked with in the past in in my capacity as a PRUH Maternity Voices Partnership Chair, and I'm now very excited to speak to her today about high risk pregnancies and what that means for the individual.
1:18
Daisy is a midwife.
She has loads of experience across different settings.
She's also a mum of three like me and I'm very excited to be chatting to you today because this high risk label, I think it's banded about a lot with not very much understanding about what it means.
1:40
So thank you for agreeing to come on.
Pleasure.
Thanks for having me, Erin.
I'm excited to be here.
Do you want to talk a little bit First off about what, what does that high risk label mean?
What is high risk?
Yeah.
So I wanted to talk to you about about what being high risk means because I I do semantic classes as as I know you do as well Erin.
2:05
And women will often say, oh, like I'm not allowed to do that because I'm high risk or Oh, my, my pregnancy is high risk.
And it they're given this term of high risk, whether it's whether they're given that term by themselves or whether they're given it by a consultant or another midwife.
2:21
And it's a sort of catch all term.
It's so incredibly vague and broad.
And it can mean a woman who has a serious cardiac defect, she's diabetic.
She's, you know, got a really, really difficult history in terms of having babies.
2:37
And you know, there could be some really, really significant difficult sort of medical possibilities there.
Or it could be somebody who, when they had their first baby, lost a tiny bit of excess blood, a tiny bit more blood than we would have liked them to have lost, and they could be labeled high risk.
2:54
And obviously those two women have entirely different chances of sort of adverse incidents occurring.
And unfortunately what what often happens when somebody is defined as high risk is it really limits their or they feel as though it really limits the choices that are available to them in terms of their pregnancy, but also where they might want to give birth.
3:15
So very often women will say I'm not allowed to give birth in a pool because I'm high risk or I'm not allowed at home birth because I'm high risk.
And what I really wanted to do on this podcast, what I really wanted to discuss is actually what are the options available to you?
And I'm going to kind of up in, in 2 seconds and say any options are available to you.
3:35
But also, let's look at sort of how you might weigh up those risks and benefits and how you might ask questions of your care providers.
And because I think it's no secret to say that at the moment, maternity services are in a difficult place in the UK.
And how I think that's presenting to women is that they're not necessarily getting all the information they need in order to make a choice about their care.
4:00
So I think that's what that's what we're going to be looking at today.
And in terms of what high risk means, risk is, is a word that kind of came from really the financial sort of, you know, area of of work.
And we've tried to sort of apply it to humans.
So we said right, this lady here, lovely lady, low risk, this lady here, high risk needs to stay in hospital.
4:20
But actually we know that humans don't work like that.
We know that bodies don't work like that and we know that labour and birth and women, we can't always predict what's going to happen.
So risk is really looking at what is the chance of an adverse incident occurring.
But what we also have to think about is what is an adverse incident?
4:41
Because for some woman, some women, an adverse incident might mean an emergency cesarean.
That might for her be something that she really has to avoid at all costs.
For another woman, she might think, you know what, I'm not bothered about an emergency section at all.
That's fine.
What I really can't bear to happen is a perineal tear, for example.
5:00
So that might be an adverse incident to her.
So what we need to think about really, really carefully when we're looking at risk is personalization.
So looking at what is important to that woman, what what is important to that family, because it's different.
5:15
And it's not for us as healthcare professionals to say what is important to them and their family.
Yeah, I think this is, I think this is the issue with that.
The high risk label, well, there's a few, there's a few issues I think one is, is the the, the terminology high risk.
5:32
I think risk is you know it immediately, you know makes you feel quite anxious and quite nervous and it sounds instantly quite negative.
Whereas when you said chance it didn't sound as it didn't sound as worrying.
So I think the language is is problematic, but I also feel like this when we talk about high risk, it's almost a tick box exercise.
5:53
So you kind of tick, you're over a certain age tick, your your BM is over a certain, you know a certain score and so you tick certain boxes and therefore you're high risk and therefore you can't have waterbirth and you can't use the birthing suite and you know the birth centre.
6:10
And you're right, it should be individualised, looking at that individual person, their Unix unique circumstances, their unique pregnancy and what's important to them.
Because I think that's the bit that's missing quite often is, is the personal personalization and thinking about what's important to them.
6:29
Because quite often I think the high risk category is labeled for people because of what the care provider thinks is important.
Yeah.
And also what the care provider thinks is a high risk because actually we take risks all day long.
You know, every time we get in a car, I think hardly any of us sit in the car and go right.
6:48
There's a mediate and moderate chance risk that I might, you know, hit another car.
We don't do that because it's something we do all day, every day.
But for some reason we've, we've become almost obsessive about it in maternity care.
And we know that in any person's pregnancy there is a chance of certain certain outcomes occurring.
7:07
And actually what what we're not very good with both both as healthcare professionals and also people who use those services, we're not very good with uncertainty.
We really like certainty.
So we often like somebody to say right, you have a one in 2000 chance of this happening, you have a one in 500 and therefore you know we need to treat you in this way.
7:24
But actually sometimes we don't know.
And you know, as you said using the maternal age example, we may know that, you know, certain things are slightly more likely in a woman who's over 40.
However, if you've got a woman who's had a spontaneous pregnancy and she's 42 and she's fit and healthy and she doesn't smoke and she uses the gym, her chance is probably actually less than a 30 year old who you know, has gone through lots of medical treatment to get there and has a raised BMI and has some blood pressure issues and is diabetic.
7:54
So we that's what I mean about personalization.
We have to look at that person individually and also respect their wishes.
If if they say, if we say to them right, actually we would prefer you to be in hospital because we're a little bit worried that there might be an increased chance of you having a bleed after you've had your baby.
8:11
We think that risk might be about one in 500.
And the reason we'd like you to be in hospital is because we have easier access to drugs and doctors.
And that person says to us, do you know what?
Actually one in 500 to me is an okay risk.
8:26
It's an okay chance.
That means I've got 499 chances of that not happening.
And for me, I'm prepared to take that chance.
Then we have to go okay.
Great.
I've I've told you those risks and not only that, but I'm prepared to care for you with with those risks because it's not my risk to take.
8:42
And for other women we might say you've got a one in 1000 chance and she goes, well that's really high risk.
I don't want to do that.
I want to be around all the drugs and around all the doctors.
And so it's our job to absolutely respect that.
And what I think it's important to be realistic about.
8:58
And this isn't in any way to kind of slate maternity services because I've worked in them for a really long time.
But I think a lot of women are finding that that's not what they're encountering at the moment.
And So what?
Another thing that I wanted to focus on in this podcast, and I know we have limited time, so I will try and keep it succinct.
9:17
But one thing that I wanted to talk about was actually how you can advocate for yourself.
If you're coming up against a midwife or a Doctor Who's saying, well, no, that option isn't there for you, actually, How can you work around that?
Because that's not true.
That option is there for you.
So how can we without being shouty and aggressive?
9:34
You can if you want, but how can we sort of effectively communicate?
Actually, this is what I'm going to do and I expect to be supported in my decision.
Yeah, I think knowing your rights is really, really important and I think a lot of people don't realise they have rights when when they're pregnant for lots of different reasons.
9:55
And again, you know, use of language, the way the options are presented to you will kind of maybe imply that you don't have rights and that you don't have options.
So I think it is important First off that people realise that they do have rights and they hand bath how and where they want.
10:11
But also like you say how to advocate for yourself and how how to have those conversations.
So how would you advise somebody who's got a high risk label and it's it's coming up against that that that brick wall of no you can't do that, that's not an option for you.
How should they navigate that?
10:27
I I think the first thing is, you know, you were saying about use of language often can trick women into feeling that they don't have options.
So I think the first thing might be to understand what that kind of language sounds like and and just have a little red flag in your mind if you hear certain phrases.
10:42
So if you hear we need to from a care provider, then you get a little ping in your head.
Oh, hang on, let me just hear what they need to do because I'm just going to check in my head that that that is acceptable to me or you have to.
So you have to be induced before 42 weeks.
11:01
Absolutely.
You don't have to.
So you have to is a red flag.
So we need to you have to we always but we all you know we always do this well I don't care that's that's not what what we're doing right now anything which is kind of very broad like that you know and tells you what you should be doing it needs to raise a little red flag.
11:25
So I know that Erin in in better birth and in the MVP and then I mean it's huge, the brain acronym and it's huge for good reason.
It's it's really, really effective way of advocating for yourself and I'm going to look at that now, but I'm also going to go a little bit further with that.
11:41
So the brain acronym would be asking the doctor or the midwife what are the benefits of what you're what you're recommending to me they are would be what are the risks of what you're recommending to me.
Because there are risks and actually what we're not very good at at the moment is explaining the risks of the intervention that we're offering.
12:01
And a word, I'm already going for topic, but I think it's important, a word that I wanted to bring up because I think it's vital.
It's a big word, but I think we need to understand it is iatrogenic.
And what iatrogenic means is a complication which has been caused by a medical intervention used in order to prevent a different complication.
12:24
So for example, we might give you, you know, so say for example, in elderly care, you might give somebody a drug to bring down their blood pressure and as a result they keep having falls.
So those falls are right atrogenic because we've caused them by reducing their blood pressure so quickly.
12:43
And this happens in maternity care as well.
We might, we might recommend to you that we induce your labour because you've got a large for gestational age baby, which we'll look at a bit more in a moment.
But by doing that induction, we then 'cause maybe a third degree tear, maybe a postpartum hemorrhage or maybe something which we're not even very good at measuring in the NHS at the moment, which is birth trauma, which is huge.
13:11
We've got a whole birth trauma inquiry going on at the moment because we're recognizing now that this is an enormous problem and it's been overlooked for many years because medical professionals and family members will say, oh, come on, get over it, You've got a healthy baby.
13:27
That's all that matters.
It really isn't all that matters.
It's really, really significant and women can hold that trauma for a really long time.
So we have to think of that as a an iatrogenic harm that's been caused by another intervention.
And it may be that that induction was absolutely indicated and the right thing for that woman and she made an informed choice.
13:47
And that's the most important thing.
But what Erin and I are very keen on, are very keen to happen is that women aren't making an informed choice and that you do understand that you have that choice.
And actually, is that induction really necessary?
Is that birth on the labour ward really necessary?
14:03
Is that CTG really necessary?
Is that extra scan really necessary?
All these things that might be offered to you, So going back to the BRAIN acronym.
So the risks of that induction, for example the risks of might be increased perineal trauma, increased bleeding.
14:21
The A would be alternative.
So what is the?
One one thing I want to say to just interrupt you is another little red flag.
You're talking about little red flags.
If somebody says there's no risks, huge red flag, because there's nothing is without risk.
14:37
And you know, you might hear if you're offered a sweep, for example, the risks, oh, there's no risks, everything has risks.
So that's definitely all ping in your head.
If someone says oh, there's no risks.
Yeah, because that that either means they're lying or if let's be a bit kinder, maybe it means they don't know the risks, which is actually worrying.
14:57
You know, if you're a healthcare professional.
And it might be something like a sweep where actually, you know, if I'm counselling a woman about a sweep, I will say there's a risk that I might break your waters doing this and then that puts you on a timer.
What I will say is I have never broken anyone's waters doing a sweep.
15:12
So for me, that risk seems very, very low, But it is there exactly as you said, there is always a risk.
And we do have and it's OK as a healthcare professional not to know that not to be able to quantify that risk.
You know, I don't know how many women's waters break with a sweep, but I know that it's never happened to me when I've done it.
15:32
So the alternatives would be what?
What are the alternatives to that induction?
The I would be, what is my intuition telling me?
And you've got time to make that decision.
Most of the time you don't have to make that in that appointment you can say, do you know what, I'm going to give it a couple of days or I'm going to give it half an hour, or I'm going to give it a week and I'm going to just give it some thought.
15:51
What is my intuition telling me about this?
And in that time, go away, talk to people, access information, like better birth access information.
I run a business called Mama Sanctuary where I can give you evidence based information.
Come to me and ask at your NHS appointment to speak to the consultant midwife.
16:09
The consultant midwife is a role, It's a senior experienced midwife who is there to give you this kind of information.
What I will say is that at most trusts, there's only one, maybe two, and they sometimes have a long wait and you don't always get to see them.
16:25
But it's certainly worth asking that that the service is there if you want to, but there are private services if you're struggling on the NHS and the end part of brain means nothing.
So what happens if we do nothing?
What happens if I choose just to continue as I am for a little while?
16:42
What what, what is the problem there?
So I think the main things there are just not to feel pressured into your decision because there's very, very few situations in maternity where it's do you know what, we need an answer now and and you'll be aware if it is a we need an answer now type thing.
16:59
I think if and again you know clients, I've had had clients that have experienced this and I think it's worthwhile just just flagging it if you're at an appointment and and they're often you're in it.
So for example, you use the example of an induction and they offer you the induction and you're thinking right.
17:17
Well, I've got time to think about this.
And no, I don't want to make a decision right now.
What should they say if they get told?
Oh, but if you don't book it in now, then we won't have space for you.
We need to, we need to book you in.
And you can just cancel it later.
But I think I suggest that, you know, let's just book it in now, because if you don't book it in now, you know and you change your mind.
17:35
We can't fit you in.
Firstly, that's not true.
We, you know, we have to be able to fit you in.
So the absolute worst case scenario would be that there genuinely is not capacity for the induction on that day, in which case we would look at other local units.
17:52
You know, if you decided actually on that Thursday.
I really do want my induction and there genuinely isn't space.
And sometimes that happens even not because there's so many inductions that day, just because the labour Ward's really busy and we don't want to start anything, you know, and not have capacity to continue it.
And so then we would look at other units or we would say come in, we'll monitor the baby to keep an eye on them.
18:15
But absolutely that is not, that's not your problem as a as a pregnant person, that's not your issue.
And we shouldn't be carrying out interventions due to our capacity.
That's not, that's absolutely not your problem and that is another pink red flag in your head.
If they're starting to talk about capacity, that's that's not your issue I think.
18:34
That's I think I can imagine that's quite scary as a pregnant woman to hear.
But I hope that if women listen to this, they're able to go.
Now I'm going to, I'm going to just get rid of that one because that's an easy one to get rid of.
That's not my problem.
And actually, you know, I have a right to to choose, you know, not to have my induction on that day.
18:54
That's absolutely fine.
The other thing I think is really important to communicate.
So we were talking about how to communicate when your pregnancy is high risk.
So kind of using the BRAIN acronym, but even do you know what even more basic than the brain acronym?
I think often women say their pregnancy is high risk and they don't really know what that means for them.
19:16
So it's perfectly acceptable to say to a midwife or a doctor, can I ask, what is it you're worried about?
Because for this woman, they might be worried about.
Right.
We're really worried about the blood flow to your baby.
And so the risk for you is around the growth of your baby.
19:31
It's around the oxygenation of your baby.
It's around the health of your baby.
For other women, we've got no concerns about that at all.
The baby is not the issue.
For other women, we're worried.
She's got lots of fibroids in her uterus, so we're worried about her womb's ability to contract down and stop that bleeding after birth.
19:47
So actually, just because she's high risk of bleeding doesn't mean she's high risk of fetal hypoxia.
It doesn't mean she needs induction because induction isn't going to change her bleeding risk.
In actual fact, it's probably going to increase it.
So let's not induce that woman.
That's a good idea.
So let's look at actually what is that woman's risk, what is my risk?
20:06
You know, it's really important that that women and people understand the risk that we're talking about because being high risk is not a blanket statement.
It doesn't mean you're high risk of everything.
It is probably just one thing.
And actually, that risk might be tiny, tiny, tiny.
20:21
Just because you've had a bit of a bleed before doesn't mean you're going to bleed next time especially.
Sorry, that's.
A really good point actually because again I think this is a really, really common thing that I I hear you know on my Instagram and from previous clients that they they're they're marked as high risk because they had a big bleed in the last birth.
20:38
And this is something that gets put in sent, sent to my DMS quite often.
And the first question I'll ask is, well, what happened in your last birth?
Because no, if you if you had a really heavily medical intervention LED birth last time and now you're planning on having a physiological hands off home birth and then potentially your risk of hemorrhage is completely different compared to your first time, it doesn't necessarily mean you're going to have a second time round.
21:07
Of course.
And that's a vital, you know, if we've got a woman who had a home birth first time and a significant bleed, and again, this is personalization of risk.
So I've got a woman who comes to me.
She's had a home birth, She's had a beautiful, straightforward, normal length labour, very minimal tearing and she has a big bleed.
21:26
I'm going to be more worried about her than a woman who's had a long induction, A forceps birth, 1/3 degree tear.
Obviously she very few women are going to go through a massively long label with the four steps and a third degree tear and not lose more than 500 mils.
That's absolutely to be expected and I wouldn't be particularly worried about her.
21:45
But if we take, for example, that home birth lady, if she came to me and said I'd still like another home birth, that's completely fine.
We'll talk to her about her risk.
We'll say, you know, there is a slightly increased chance of you having a bleed this time.
I don't know that.
I don't know the exact chance of that happening.
22:02
You're still far more likely not to bleed.
These are the things that we can do to reduce your risk of bleeding.
So we can use an oxytocin to help reduce that risk or we can try it physiologically and if it looks like you're bleeding then we would you know, give you that that injection we.
22:18
And as long as she knows that you know what what the, what the risk is is that there's a delay in transferring into hospital as long as she understands that and what the implications of that are, that option of home birth is still available to her and it's still her risk to take, not mine.
22:33
So that's what women have to understand.
And you know, it's very hard at the moment going to women's houses post natally and hearing them say, oh, you know, I I just didn't even think about looking into it antonatally.
I just trusted that they knew what they were talking about.
And I think the reality is we know what we're talking about now in terms of very medicalised labour.
22:53
But actually our our protection of the Physiology of labour is reducing.
And so if that was the kind of labour that you want, you need to go in kind of eyes wide open, advocating for yourself.
Should we, should we do an example?
23:09
Should we do a?
We've done a little bit around hemorrhage, haven't we?
But the other huge one that comes up again and again and again is I'm not allowed to have a home birth or I'm not allowed to have a water birth.
I'm not allowed to birth on the birth centre because my baby's really big.
So the first thing to look at here is, how have we diagnosed that your baby's big in the 1st place?
23:33
Because actually the nice guidance which is the national guidance around looking at fetal growth recommends we have a scan at 12 weeks, so the first trimester and recommends we have a scan second trimester, so that's around 21 weeks.
And it says that for straightforward ongoing pregnancies no further scans are required.
23:54
At many trusts in London now they are doing a third trimester scan.
It's important to recognise that that is not yet evidence based.
It's entirely your choice, as are all scans, and mainly that scan is being used for evidential purposes.
24:10
At the moment it's being used as a research scan and so if you want to decline that, you can absolutely decline that.
You can decline anything.
But just to know that I think most women don't realise that's a that's a scan for.
Business.
A lot of my clients do not realise because they all because obviously because my local hospital, they all they they all get offered their trimester and and again it's about understanding risks, isn't it?
24:35
Because I think a lot, there's a lot of people think oh amazing, I get an extra scan, I get to see my baby again and yes, that's definitely a benefit.
But the risk is that a third trimester scan is likely to be less accurate.
It's harder to measure the baby accurately, and they potentially could say your baby's really big or your baby's really small, or your baby's growth has dropped off because.
24:57
Yeah, yeah.
And you know, we're at our local hospital.
It's an incredible fetal medicine center and women come from all over the country, all over the world for the expertise of that center.
And it's incredible.
But what it means is because of the because of how incredibly high quality it is, they are picking up the tiniest of things.
25:19
And sometimes if I I'm looking after a woman and I think, oh gosh, I've never seen that on a scan before, what does that mean?
I go away and I spend a lot of time looking at what that means and the implications of that for her labour.
And ultimately what you find is that it says it's of no clinical significance is what they write.
25:35
So they found this, they found this finding on the baby.
The woman's got herself in a panic because they've said, oh, there's this thing to do with your baby's heart and she's gone, oh gosh, my baby's got a heart problem.
But actually it's of no clinical significance.
So we're finding all of these things that aren't of clinical significance.
Obviously, we're finding things that are of clinical significance and thank goodness we are.
25:54
But what we know with large for gestational age or big babies is that scans have at least a 20% margin for error.
And I think, Erin, you did a survey on that with the MVPA while back and you know, huge numbers of women were saying my baby was predicted to be 10 lbs, it was 7 lbs.
26:14
Endless.
You know, it goes on and on and on.
And I think probably most women listening to this podcast can think of examples where friends of theirs have been told the same and what that LGA means, large for gestational age.
What that diagnosis means is a huge amount of anxiety for women, very often anxiety for the care provider because the the care providers are thinking, Oh my goodness, this is a big baby, the big baby, big baby.
26:37
And what those women are likely to be offered is they're likely to be told, told, slash, offered, hopefully offered an induction of labour to reduce the risk or or even exclude the risk.
Which is not true of the baby getting stuck.
And when we say to a woman your baby might get stuck, that is terrifying.
26:55
Anyone would find that really, really frightening.
That's a horrible image, your baby getting stuck.
But let's for a minute a bit like we unpicked what high being high risk means.
Let's unpick what your baby getting stuck means.
So it could mean two things really.
27:10
It could either mean that labour doesn't progress because your baby just isn't going into your pelvis and therefore your labour just isn't progressing.
And that's not really very exciting.
Ultimately, what happens is that you probably have a cesarean because your labour didn't progress.
27:27
That's not, it's it's not, you know, it's not a lovely outcome, but it's not a really, really terrifying outcome.
It's not an emergency outcome.
It's not my baby stuck.
Everything's terrible.
It's just quite oh, everything's plotting and we're not really going anywhere.
So that's one eventuality of a baby getting stuck.
27:44
The other one that that women generally are thinking about is something called a shoulder dystosia, where that one of the baby's shoulders get stuck behind the pubic bone.
What we know is that that can occur in any in any pregnancy, not just with babies that are bigger.
28:00
But what we also know is that in 90% of those emergencies, it's resolved with what we call simple manoeuvres.
So basically one manoeuvre, the midwife does one thing, usually lift your legs right back or get you on all fours and the baby delivers itself.
That's not scary, that's OK And the vast majority of those babies have no long term damage.
28:20
In fact, I'm going to just look at my CHEAT SHEET here.
But so 2 to 16% of babies who have a shoulder dystosia have an injury to their nerve.
However, the vast majority of that say 2 to 16% / 90% of those resolve really quickly.
28:37
Very, very few.
We're talking about a minute, few have any lasting damage.
And what we also know is that induction doesn't exclude that risk and still have a shoulder dystosia with an induction of labour.
In fact, it may be more likely because you're not moving around and you've probably got an epidural in.
28:55
So we have to think about looking beyond the terminology that medical professionals are using.
If they're saying to you we want to induce you to stop your baby getting stuck, who's going to say no to that?
Of course, say yes to that.
But firstly, is induction going to stop that risk?
No.
Secondly, what does getting stuck actually mean?
29:11
How serious is getting stuck?
Because in most cases it's really not serious.
And also most big babies will deliver themselves or the, you know, the woman will birth them absolutely beautifully.
So it's just looking a little bit beyond the what's what you're being told and that's quite hard to do on your own.
29:29
And so if you want to do that alongside somebody, speak to your consultant midwife, speak to a senior midwife, speak to Erin, speak to myself at Mama Sanctuary.
You know, we're here for you to be able to kind of help you unpick those risks and try and help you personalise them a little bit as well.
Yeah, it's.
29:45
I think having some context is so important because one of the other things that I've I've found quite a lot with, with clients and followers who have got a large for gestational age baby is there's context missing around, you know, the, the, the, the size of the mother, the size of the father.
30:07
You know, I had two clients who were like they booked on a course with me and they said, oh, we've been told that we need an induction because the baby's over the 19th centile.
And obviously this is on zoom because a lot of my clients are on zoom.
So I couldn't see how tall they were.
So I asked them or how tall are you?
30:23
And they were both like 6 foot and I said well then your baby is going to be high up on that on that chart you're, I mean that's been more concerning if your baby was small because genetically you're you're growing a baby that's appropriate.
For you, Yeah, absolutely.
30:39
And again, this comes back down to personalization, doesn't it?
You know, and in some trusts across the country, they use personalized growth charts.
So they look at that woman's height, her BMI, her ethnicity, ethnicity is a huge factor in the size of a baby.
30:56
We know that a Japanese lady is much more likely to have a smaller baby than a W African lady.
This is, you know, this is not difficult to comprehend.
And also, what size baby has she birthed before?
Because you know, when we weren't doing these 36 week growth scans, we often didn't know the size of the baby.
31:16
And you know, I've had women come through who've had two babies before, you know, 9#69#9 perfect water burst.
She's now been predicted an LGA baby and she's been advised you need an induction.
Hang on a minute, she's done this twice before.
She's burst them without any problems.
She is going to have an LGA baby because she has done twice before as long as we've ruled out that this isn't a baby with excessive.
31:38
This isn't an excessively grown baby caused by excessive insulin due to uncontrolled diabetes.
That's a very, very different risk to a well woman who's just got a slightly bigger baby.
You know, this this is very, very different.
And and it's about personalizing what how risky is that LGA baby and in most cases very, very not risky.
32:02
And this is the thing, isn't it?
Cos I think as the as the years have gone on I mean my eldest is 12 this year so I've got over a decade of experiencing maternity care over the years and I think probably what wouldn't have cost you and dropped you into a high risk box a decade ago will now.
32:24
So that that bigger picture of looking at previous births potentially is actually really important.
I mean all all three of my children, I'm, I mean, I'm Asian, my husband's Chinese as well.
We are going to have smaller children.
32:39
You know, all of my babies were small.
They did get progressively bigger and that's.
What we expect as well?
Yeah, but I mean, my first, my my eldest, she was 6 lbs And she was classed as small for gestational age.
But she's she wasn't, she was just small.
32:57
And that was appropriate for my genetics.
And again, there's a difference between a small for gestational age baby and a baby who is severely growth restricted.
Because of.
A poorly functioning placenta.
There's a big difference between those two things.
I think the other really important thing to mention is you're talking about maternity care over 10 years.
33:16
I mean, I'm looking at over sort of 19 years since I qualified.
I wrote an article when I just qualified because I happened to be working as a newly qualified midwife in a trust which had the highest section rate in the country, which at the time was 32%.
And I wrote an article about how scary it was that 32% of our women were were having emergency caesareans, I mean 32% we dream of now.
33:41
And actually what what we need to look at is, you know, over the last 10 years, 20 years, our induction rates have skyrocketed.
Our Caesarean rates have skyrocketed our rates of the things that they are trying to reduce.
So we're talking about still birth and birth injuries.
34:00
So cerebral palsy, the rates of those outcomes has not changed.
Yes, we are intervening more to try and reduce those things, but it's not working.
It's not working.
So we and actually it's causing harm.
34:15
You know, we know that cesarean section, we're really lucky in this country is incredibly safe.
And for most women and babies it's incredibly safe.
But multiple cesareans carry a significantly more risk.
And then you look, when you look at countries where they have huge caesarean section rates, they're having to now develop whole specialist clinics to cope with the complications of multiple Caesarean sections.
34:37
And we will be going that way as well.
And that's not to scare women off having Caesareans.
It's just to say that again, it's looking at that iatrogenic harm.
We are causing harm by trying to reduce the risk of cerebral palsy still birth and not reducing those things at all.
34:54
There's, there's so many, there's so many other things to to consider, isn't it?
Because you know everyone, I think, I think still birth is the one that gets trotted out the most.
I think when we talk about risk and you don't want a dead baby, do you?
And obviously that yes, of course you don't.
35:11
But there is a load of other risks which we have to consider with accepting the intervention.
Physical trauma, mental trauma, you know, birth trauma, you know the effect that's going to have on your postpartum period, your feeding journey, whether you plan to breastfeed or chest feed or not, you know, and how you bond with your baby and how that affects your whole family, you know.
35:35
These are things which I think possibly we don't think of and we don't realise the impact of.
Yeah.
And I think, I'm sorry, I was just looking for a quote that that backed up.
Exactly.
Here we go.
I've got it.
So I saw a quote by a midwife who I believe is now an independent midwife called Amity Reid.
35:54
And she said survival of childbirth isn't a benchmark of quality care.
So we shouldn't be saying, well, you survived and your baby survived.
That is the absolute basic.
And we know tragically that that sometimes babies die, but it it should be the basic level of care that mum and baby survives.
36:12
We shouldn't be saying, oh, you know, you're lucky you survive.
That's that's that's we and we shouldn't.
I also said that we shouldn't be weaponizing or glorifying survival.
You know, we shouldn't be using death to coerce women into making decisions and nor should we be glorifying it.
36:30
Will your baby survive?
Well, as they should, you know.
So yeah, it it we should, we shouldn't.
That's another red flag.
You know, it's it's OK We can be talking about risks of still birth, but we shouldn't be saying we need to induce you.
Otherwise your baby will die.
Actually, you know, the chance of still birth is so minimal for the vast majority of women babies.
36:52
Then one thing that we've mentioned quite a lot is, you know research and statistics.
And I think it's also maybe a point that's quite important just to draw upon a little bit, because I think quite often we get told there's a like you get a vague kind of statistic like the chance of something triples or.
37:11
Double s.
And that can sound terrifying.
Like one of my clients I tell I tell all of my clients this story.
One of my clients got told that the risk of still birth increases 6 fold if she didn't, you know if she stayed pregnant.
And that sounds terrifying.
A66 fold increase of still birth.
37:28
But when she actually asked for the statistics and also you know, what's the absolute figures, what were we actually talking about?
It was a one in 3000 chance, six fold increase to six in 3006 In 3000 is a naughty .2% chance of something happening.
37:44
There's a 99.8% chance of that not happening.
We're.
Talking about going from an exceptionally tiny risk to a tiny risk and again, just going back, I know I've said it again and again, but it's that personalisation.
Is that risk acceptable to that woman?
Because it might not be, and that's fine.
38:00
But she needs to know.
She needs to know the information whether you know if she's going to make an informed choice and it's the same with, you know, if your waters have been broken for a little while in terms of inducing your labour.
We'll say you know the risk of infection.
Double S again it double S from a small number to to a small number and that might be significant to you.
38:18
In which case accept the intervention that what that we're offering.
But you have, you have to have the information in order to be able to make an informed choice and that's what that's what we really need to be promoting amongst women and birthing people is that how can I access that information, Where can I go for that information.
38:36
I think you know some really good sources of information would be certainly to follow to follow better birth association for improvements in maternity services.
So that's aims.
They're really, really good as well.
There's a website called Evidence Based Birth.
That's.
One of my favourites is.
38:52
Brilliant evidence based set Doctor Sarah Wickham.
She's Doctor of Midwifery.
She writes the most incredible, really well researched books, sort of folks she's done.
Her most recent one was on raised BMI.
She's done advanced maternal age, vitamin K and TD induction of labour, loads and loads.
39:12
And it's just worth seeking that additional information.
And, you know, if you feel like you're being dissuaded from doing that by your maternity service, you know, Ping, that's another red flag.
You should be.
You should be encouraged to be finding this information, Absolutely.
39:29
Yeah, I think sometimes.
And again, like you said earlier, it's fine if you keep a fighter doesn't know because they might not know.
They might, you know, they might, they might, they might be on autopilot saying these things and not actually know where the evidence come from because it's just in guidelines.
It's in the policy and they've always said it.
39:46
And then no one's ever challenged them before and said, well, where's that come from?
And that's fine, but then they can go away and have a look and get back to you again.
It's probably not that urgent.
You probably don't have to make a decision on the spot.
Or you can go and do your own research, just just to add to your list, because I said I recommend all of those sources to to my clients.
40:07
I also think Doctor Rachel Reed's blog, I think absolutely a really, really good one and Doctor Kirsten Small's blog, which is quite niche on fetal monitoring and CTG.
But actually I think that's it's a really, really good source of information.
40:25
If you're being told that you have to have a CTG because you're high risk, then I think that's probably a really good source of information to unpick.
But actually, what's the impact of that CTG and IS, is the use of the CTG evidence based in the first?
Place and is the use of the CTG increasing my risk of anything else?
40:44
Is it going to cause me any iatrogenic harm?
IE is it going to increase my risk of having a cesarean section?
Yes, absolutely it is.
So the information that you choose to seek will depend on your individual risk factor I guess And and the other thing to bear in mind is that risk is ever changing and dynamic.
41:05
So you know, you may have, they may have thought you were high risk at booking of something, but actually as your pregnancies progressed, you know, you were high risk of preeclampsia, but actually your blood pressures remain perfectly normal and therefore that's no longer a risk.
And so just because you were labeled high risk at one point doesn't mean that can't change as well.
41:24
And and there should be a red flag in yourself as well if you ever hear yourself saying I'm not allowed to do that because I'm high risk, you're, you're allowed to do anything, it's your body, it's your choice.
Just make sure that what you're doing is, is informed.
Yeah, Yeah.
41:40
Thank you so much for coming it.
Was a pleasure.
I could talk for hours, but I think we.
Too I think we've crammed tons.
We have.
One podcast episode, and I think it's going to be really, really, really useful for for anybody that's listening.
If anybody does want to come and find you and speak to you, where can they find you?
42:00
So on Instagram, Mama Mama under score Sanctuary or www.mamasanctuary.co.uk and there's a contact form on there you can find out sort of what ioffer it's.
It's not independent midwifery, so many women don't want to go for an independent midwife and nor should you have to.
42:17
The NHS should provide what you need, but it may be that you want something alongside that you may want somebody just to talk through your appointments alongside you or post.
Naturally I can support you.
Have a look and if there isn't something there that you think is it tailored to you, speak to me because we can, we can work something out.
42:36
Thank you so much for your time.
Thank you.
Pleasure.
Thank you.
Take care.
The Better Birth Podcast and all of its content is for educational and informational purposes only.
42:55
You should consult your midwife or your doctor for anything in relation to your own pregnancy and birth.
The opinions and the views of the guests on The Better Birth Podcast are their own opinions and do not necessarily reflect the opinions of Better Birth or Erin Fung.