The National Institute for Health and Care Excellence (NICE) has just published new guidelines that mark a significant shift in how expectant mothers are cared for during labour. The new guidelines emphasise a risk-based assessment of mothers-to-be and recommend that those who are considered to be at "low risk" of complications during labour should be encouraged to consider either a home birth or a midwifery-led unit when deciding where to have their baby.

NICE suggests that these alternatives to the traditional hospital birth would provide the expectant mother with a better experience and are less likely to result in medical intervention. Those considered to be at low risk would be mothers whose pregnancies and deliveries have been without complications.

The Penningtons Manches clinical negligence teams has some concerns about the NICE guidelines. Says associate, Naomi Holland: “The recommendation to assess the relative risk of expectant mothers is a sensible one and care and resources (in terms of number and expertise) can and should be tailored accordingly. Nevertheless, patient safety is paramount and these new guidelines raise concerns that proper safeguards need to be put in place before the recommendations can be adopted and implemented, particularly in relation to home births.

“There have been wide reports of a current shortage of midwives. Home births currently account for only around 2% of the 800,000 deliveries in the UK each year. The new guidelines would be expected to lead to a dramatic rise in home births, which would require a corresponding increase in the availability of midwives able to manage home births. There is concern that this cannot be achieved safely with the number of midwives currently available.

“Whether an expectant mother opts for home birth or a midwife-led unit, it is imperative that fast and easy access to experienced senior doctors is available if complications develop during labour. It is sobering to note that around 15% of deliveries end in an emergency Caesarian section when the labour does not proceed as expected and complications develop. The further the mother is from an operating theatre, the greater the risk of injury to both her and the child. The Royal College of Obstetricians and Gynaecologists (RCOG), which represents the UK's 10,000 maternity doctors, warns that measures are needed to deal with those cases in which complications arise during labour. The RCOG recommends, for example, that emergency transport needs to be readily available to transfer women to hospital at short notice if they develop complications or need pain relief.

"The statistics are clear that complications can and do arise in the course of labour where emergency intervention is needed to safeguard both mother and child. We would suggest that a patient's distance from hospital and availability of midwifery care should be a key factor in deciding whether a home birth is a safe option. Patient choice is welcome but the patient needs to be fully informed of the risks of each option for delivery.

"Legal claims for injuries sustained during birth represent by far the greatest proportion of claims against the NHS by value.  The NHS Litigation Authority (NHS LA), which represents the NHS in legal claims, reports that around 70% of these injury claims arose from failings in monitoring fetal heart rate and management of labour. If this is happening in fully staffed labour wards, then more needs to be done to ensure proper and effective mechanisms for transferring care to properly staffed hospital maternity wards where complications arise if home births are to become the norm. However, if these aspects are fully considered and resourced, then we can see the benefits for straightforward births – particularly if this frees up resources for the more complicated deliveries."