Concern raised over national guidelines around labour

The former master of the National Maternity Hospital has called for a review of the national guidelines around labour, warning the current recommendations can lead to dangerous outcomes for women and babies.

Dr Peter Boylan, who highlighted his concerns in an opinion piece in The Irish Times, described how the definition and management of the early stages of labour risks catastrophic consequences.

He told RTÉ News that it is in the interest of the Minister for Health Jennifer Carroll MacNeill to review these guidelines from both a safety and cost saving approach.

"It needs to be looked at because from her point of view and the state's point of view this is going to result in more litigation because there will be more adverse outcomes, inevitably," he warned.

He referred to the recent findings of what he called the "shocking Ockenden report" in the UK, which found that more than 500 mothers and babies suffered avoidable harm or died.

Experts found adverse outcomes were linked to multiple factors, including failures in the monitoring of babies, and that the systems of oversight were "no longer fit for purpose".

Dr Boylan said: "We don't want to import into Ireland the disastrous approaches that have resulted in so much suffering in the UK."

He said he is worried that a "refusal" to accept a diagnosis of labour at less than 4cm dilation could lead to endangering the lives of women and babies.

"The guidelines are silent on how a woman is supposed to know at home that her cervix has reached 4cm and that makes no sense whatsoever," he said.

He is also worried about guidance around fetal monitoring in labour and claims there is no rationale around it not being carried out until 4cm dilation.

"The guidelines say you don't need to start monitoring the baby's heartbeat until the woman is in the first stage of labour which they say starts from 4cm," he explained.

"That has associated risks obviously because you are not listening to the baby's heartbeat," he added.

'Latent labour'

Since the launch of the National Maternity Strategy in 2016, Ireland has implemented guidelines and protocols to ensure high-quality maternity care for the tens of thousands of pregnant women and their babies born in Ireland every year.

This was introduced to ensure standarised care across hospitals, regions and clinicians.

The National Women and Infant's Health programme is instrumental in developing these guidelines alongside the Institute of Obstetricians and Gynecologists, and they are updated every few years.

The latest publication of these clinical guidelines has come under criticism.

Dr Boylan described how the ongoing use of the term "latent phase of labour" is a cause for concern as it states that labour does not start until the cervix is 4% dliated.

"In other words 40% there," he said.

"So a woman can be at home unmonitored, the baby unmonitored and her wondering when should I go in, how do I know when I am 4cm," he said.

Dr Boylan explained how latent labour became part of maternity care.

He said: "The term latent labour goes back to the mid-1950s when an obstetrician in New York, Emmanuel Friedman, graphically analysed the course of labour without any intervention whatsoever.

"He found women took up to 12 hours or more to reach 4cm.

"Once they reached 4cm labour, they tended to progress much quicker.

"So, the latent phase became established practice, but when I was a medical student in the 1970's we used to hear horror stories of women being 24 or 48 hours or even longer in labour.

"That was because the latent phase was accepted."

He outlined how extensive research since then shows proof that it is "quite a harmful concept".

"We can see that from the report in the United Kingdom, where babies have suffered, babies have died and women have suffered," he said.

Dr Boylan, who has delivered and reviewed tens of thousands of births, said with the latent concept women in an antenatal ward are often told they are not in labour even when they know they are and possibly lying in pain or being sent home.

"That is just not acceptable," he said.

He added: "In my practice of reviewing cases and coroner's cases and medical-legal phases, the latent phase is creeping in as a contributor to catastrophic outcomes.

"I am seeing that creeping in now and it needs to be revised and reviewed."