Birth Savvy Bub Savvy

08/01/2026

Caesarean rates are rising, but this isn’t about women’s bodies.

This large international review looked at why caesarean section rates keep climbing, even when guidelines aim to reduce unnecessary surgery.

What it found was clear:
• The rise can’t be explained by biology alone
• It’s happening even in low-risk, first-time births
• And it varies hugely between systems caring for similar women

The strongest drivers weren’t age or BMI.

They were:
• system pressures
• financial and legal incentives
• fear of litigation
• convenience and scheduling
• media narratives
• and women protecting themselves from poor or disrespectful care

In other words
Not a body problem. A system problem.

Caesareans can be life-saving when they’re needed.

But when they become the default, we need to ask why, and who the system is really designed to serve.

✨ Informed consent matters
✨ Respectful care matters
✨ How maternity care is organised matters

Reference:
Ojong SA, Temmerman M, Nsahlai CJF, Gidion D, Kihara A.
Why do cesarean delivery rates persistently rise despite evidence-based efforts to reduce them?
American Journal of Obstetrics & Gynecology. 2026; 234(Suppl): S569–S580.
https://doi.org/10.1016/j.ajog.2025.08.014

07/01/2026

Why do caesarean rates keep rising, despite evidence-based efforts to reduce them?

While we often hear from OBs that it is because birthing women are now older or have higher BMIs, the evidence tells a much more complex and important story.

A large international review just published in the American Journal of Obstetrics & Gynecology looked at 144 studies from around the world asking a simple question:

👉 Why do caesarean rates keep rising, even when we have clear evidence and guidelines aimed at reducing unnecessary surgery?

The answer was clear.

This is not about women’s bodies failing.
It’s about how maternity systems are designed and how care is delivered.

The review found that rising caesarean rates:
• can’t be explained by biology alone
• are happening even in low-risk, first-time births
• vary dramatically between systems caring for very similar women

If age and BMI were the main drivers, we wouldn’t see such stark differences between public and private hospitals, between regions, or between countries with similar populations.

Instead, the strongest drivers identified were non-clinical.

The review identified five main non-medical reasons why caesarean births are overused:

1. Fear of being sued
Many doctors feel safer legally performing a caesarean “just in case,” even when evidence supports waiting or supporting labour. This leads to defensive medicine, especially in countries with high litigation risk.

2. Financial incentives
In many health systems, caesareans:
• Pay more
• Take less time
• Are easier to schedule

This is especially clear in private hospitals, where caesarean rates are often much higher than in public systems.

3. Cultural beliefs and social pressure
In some places, caesareans are seen as:
• More modern
• Less painful
• More controlled
• Better for the body

These beliefs are often shaped by class, media portrayals of birth, and poor experiences of labour care.

4. Health system problems
Short staffing, lack of continuity of care, busy labour wards, and poor support for physiological birth make caesareans the “easier” option for overstretched systems.

5. Violations of informed consent
In many parts of the world, women report:
• Not being fully informed
• Feeling pressured or rushed
• Having surgery without genuine consent

The authors describe this as part of a broader pattern of obstetric violence, particularly affecting marginalised women.

The review also found three important but less talked-about influences:

1. Media and social media, which often portray caesareans as safer or more predictable than vaginal birth, without showing the downsides or recovery.

2. Provider convenience, with caesareans clustering around weekdays and office hours rather than labour patterns.

3. Mistrust of maternity care, where women choose caesareans to avoid fear, neglect, or disrespect during labour.

The paper also highlighted a global imbalance.

In some countries (like parts of Latin America and Australia), almost half of babies are born by caesarean, often without medical need.

In others (especially parts of Africa), women can’t access life-saving caesareans when they actually need them.

So the problem isn’t “too many or too few caesareans”... it’s the wrong women, at the wrong time, for the wrong reasons.

A really confronting finding is that some women don’t choose caesarean birth because they want surgery, but because it feels safer emotionally within a system they don’t trust.

That matters.

Because caesareans can be life-saving when they’re genuinely needed.

But they also carry short- and long-term risks for both mothers and babies, especially when they become the default rather than the exception.

The authors are very clear:
Rising caesarean rates are a structural and systems issue, not a failure of women’s bodies.

If we truly want to see safer, more balanced birth outcomes, we need to look beyond individual women and ask bigger questions about:
• how maternity care is organised
• how clinicians are supported (or pressured)
• how informed consent is practised
• and whose needs the system is designed to serve

👉 Not a body problem. A system problem.

What needs to change?

The paper calls for:
• Stronger informed consent and respectful care
• Payment systems that don’t reward surgery
• Better support for VBAC
• Legal systems that protect both families and clinicians
• Regulation of misleading birth information online

Women deserve respectful, evidence-informed care that supports physiological birth and surgical birth when it’s genuinely needed.

Reference:
Ojong SA, Temmerman M, Nsahlai CJF, Gidion D, Kihara A.
Why do cesarean delivery rates persistently rise despite evidence-based efforts to reduce them?
American Journal of Obstetrics & Gynecology. 2026; 234(Suppl): S569–S580.
https://doi.org/10.1016/j.ajog.2025.08.014

05/01/2026

✨ Been told you might need an induction? ✨
Feeling unsure, overwhelmed… or quietly disappointed?

An induction doesn’t have to mean a birth that happens to you.

I created my Positive Induction Online Course to help parents understand what’s really going on, feel confident in their decisions, and walk into an induction feeling calm, prepared, and supported, not rushed or powerless.

Inside the course, you’ll learn how to:

✔️Understand why induction is suggested and the different ways it can be done
✔️Learn how induced labour differs from spontaneous labour — and why that matters
✔️Make sense of timing (because when induction happens really matters)
✔️Sort fact from fiction around “natural” induction techniques
✔️Feel confident in your decisions, without pressure, fear, or confusion
✔️Create a personalised birth plan that reflects your values, even within an induction
✔️Communicate clearly with your care providers and advocate for what matters to you
✔️Work with your body and your brain to support a positive induction experience
✔️Understand how your partner can actively support you and advocate alongside you

🎁 Bonus modules included:
✨ Practical relaxation tools to help you stay calm and grounded (these are even more important with an induction)
✨ How to get breastfeeding off to the best possible start after an induction

This course is about informed consent, clarity, and helping you feel proud of your birth, whatever path it takes.

👉 Learn more or enrol here:
https://birthsavvy.com.au/positive-induction/

You deserve information you can trust.
You deserve choice.
And you deserve support. 💛

Positive Induction Online Course to gain confidence and knowledge for your birth plan. Empower yourself with expert guidance and support. Buy now!

04/01/2026

So many women are still told they need to start pushing as soon as they’re fully dilated, in the belief it will shorten labour, avoid exhaustion, protect the pelvic floor, and keep babies safe.

But…

This large new study helps clarify how second stage of labour actually works and where the risk sits.

The second stage isn’t one single block of time.

It has distinct phases:
• a passive phase, where the cervix is fully open but the body and baby are doing the work of moving down, softening and opening
• an active phase, when the mother is actively pushing

This new AJOG paper followed over 10,000 births using a delayed pushing approach. Even when there was a longer pause before pushing began (up to 3 hours), the time spent actively pushing was usually very short, often under 15 minutes.

This matters.

Growing evidence suggests that many outcomes we worry about, like maternal exhaustion, pelvic floor injury, heavy bleeding, and stress on the baby, are more closely linked to how long someone actively pushes rather than how long they are fully dilated.

The authors also note that:
• active pushing is the time of highest stress for babies
• shorter pushing is associated with less perineal trauma and lower rates of postpartum haemorrhage
• allowing time before pushing helps babies rotate and move into better positions, making pushing easier once it starts

Importantly, babies in this study were born in good condition, with reassuring Apgar scores, normal cord gases, and very low NICU admission rates, even with delayed pushing up to 3 hours.

But the takeaway isn’t about "delaying" pushing.

It’s about trusting the process, not watching the clock.

And trusting women to know when and how to push, which leads to a shorter, gentler, and safer active pushing phase.

📄 Reference:
Montfort E et al. Active Second Stage Duration Under 15 Minutes in Spontaneous Vaginal Deliveries with Delayed Pushing.
American Journal of Obstetrics & Gynecology, 2026.

29/12/2025

Such a great service from Justine.

When I visited Maymom in October they told me that they would be releasing a 'Goldi Pack' of fl**ges - 3 different sizes for you to test out. As in 'Goldilocks and the 3 bears - 1 too small, 1 too big, and 1 just right, or so you hope...

Here's a reminder that I've been selling a fl**ge trial pack (the 'Fl**ge Lending Service') - which is 3 fl**ges in any sizes of your choosing - for over 5 years!

You get 3 sizes to test for $40, including free postage. PLUS you get $20 refunded if you return them.

Yes, they might be previously used fl**ges (that have been washed and sterilised, using an at home sterlising system), but they are a trial pack - so not intended for long term use. You can then by the correct size/s and not waste money on items you don't need.

Plus, you are welcome to buy 3 new fl**ges - which for Spectra (or anything other than Medela) actually works out cheaper than these new Goldi Packs, because you get the whole fl**ge (the Goldi Packs are just the 'half' fl**ges) and a valve.

Keep in mind I also offer a free fl**ge sizing service - if you are in Perth you can come see, if not you can send me a video

02/12/2025

What doulas do goes far beyond comfort measures; the research just keeps showing how powerful continuous support can be.

A huge 2025 study of 17,831 births
(published in the American Journal of Obstetrics & Gynecology) found that when parents had doula support (both prenatally and at birth):
✨ VBAC rates were higher
✨ Exclusive breastfeeding rates were higher
✨ Preterm birth rates were lower
✨ More parents made it to their postpartum check-up

And what really stood out in this study is that these benefits weren’t limited to one group of families. They showed up no matter a woman’s background, postcode, or insurance status.

There is decades of research, from the US and UK, that show social and racial disadvantage are linked with higher rates of preterm birth, lower breastfeeding rates, more birth interventions, and poorer maternal outcomes overall. Not because of anything women do wrong, but because the system doesn’t support all families equally.

So the fact that doula care consistently narrowed those gaps is incredibly powerful. It suggests that having someone who understands birth, who protects your physiology, and who stands beside you with continuous emotional and practical support can create a buffer against the very inequalities that usually lead to worse outcomes.

Doulas don’t replace partners or maternity care providers… they help everyone work together so women feel safer, more supported, and more connected to their choices.

Reference:
Lemon LS, Quinn B, Young M, et al. Quantifying the association between doula care and maternal and neonatal outcomes. American Journal of Obstetrics & Gynecology. 2025;232:387.e1–387.e43.

01/12/2025

Vaginal breech birth in Western Australia, by Raya Tangchai

Original story here: https://www.breechwithoutborders.org/l/raya-wa/

At 34 weeks pregnant we discovered that our baby was breech, I believe she had been in this position for a while, this was my second pregnancy and my first was relatively easy and straight forward. I had an anterior placenta and felt that the two pregnancies were quite different, I could feel the kicks and movements of my son a lot more. My midwife at Fiona Stanley Birthing Centre warned me that the OBs would strongly recommend a c section but I can still have my baby vaginally if that's what I wanted, however the hospital itself was apparently very inexperienced with this and usually referred breech births to another hospital who it seems had recently stopped taking these referrals as they felt Fiona Stanley needed to gain the experience themselves being a tertiary hospital.

So with that in mind we tried everything to turn our baby, moxibustion, spinning babies, acupuncture, and I had an ECV booked in, hopeful that we wouldn't have to make that decision. The ECV at 37 and 2 was unsuccessful, and straight away the doctor told me that now they book me in for an elective c section, to which I replied "well that's not my only option?", I recall the doctor looked taken aback that I would even suggest a vaginal birth.

Anyway, I felt they clearly did not support it and said if I was adamant I wanted that they'd like to book me in to speak to a senior consultant which I agreed to, and they never even actually organised. I also booked in for a c section at 39 and 2 but still felt like this was not the route we were meant to take, just felt pressured into it. And on top of that when I tried to push this back a week the hospital told me I couldn't do that as their waitlist was full. We knew this hospital was not for us for this birth.

I did a deep dive into breech births because I wanted to make sure I was making the right decision for both of us and I was fully informed about all of my options. I was not going to be pushed into anything just for the convenience of the doctors or by them projecting their fears onto me. However, I wanted to make that choice for the right reasons too and knew that if anything went wrong it would be fully on me, and as so many people were unsupportive, I needed to be at peace with that. I spoke to many midwives, read many studies and listened to podcasts that really cemented my decision. Breech is just a variation of the norm and what the medical world did after TBT2000 was infuriating.

Anyway, my partner and I decided to change hospitals as that was the recommendation from everyone we had spoken to and we would both feel more comfortable in the hands of people who we felt actually had experience with breech babies. I had no doubt in myself but so much doubt in the people around me.

It was a very stressful week after going in and speaking to one of the consultants who said I couldn't have our baby at the alternative hospital due to my postcode, but we eventually managed to get a referral and was able to have a planned breech birth at King Eddie's. We also booked in a c section as back up on 25th Sept where I would have been 40 and 2.

The morning of 24th Sept my husband, myself, our son and dog made our way to a park near a blood bank so I could do bloods for the cesarean the next day, as by this point I had accepted the fact that this was probably the route we were now going to go down. As we pulled up at around 9:45am, I felt like I was starting to get contractions. I started timing it as I wasn't sure, we'd had a few false alarms and my labour with Caspian went in a different order with my waters breaking first. The blood bank was full of people waiting and I decided I was in labour and there's no need to wait in that line now!

We walked around for half an hour and then headed back home, certain that I was in labour and organised for my mother in law to come over to look after our son. Once she arrived we made our way to the hospital, getting there at 12pm by which point my contractions, that started at 1 in 10, was at 1 in 7.

At 12:35pm we were seen by an OB who checked the position of our girl, confirming that she was still in a complete breech position, and I was 4cm dilated. Within minutes my contractions ramped up to 1 in 2 and I knew she was ready. They were putting a cannula in my hand as a precaution and once that was done I said we needed to go, she's coming! As I swung my legs off the bed to get into the wheelchair my waters dramatically broke everywhere. I felt what I thought was a leg dangling out or the sensation of it and we rushed to the delivery room.

When we got there I just got out of the wheelchair and climbed onto the bed. The midwife who wheeled me over was still turning on the monitors, and my husband was catching up to us because he was grabbing our stuff when we rushed out. The room was not quite ready yet, but I didn't have time to wait, I knew I needed to push so as soon as I got on the bed, I got on my knees, held onto the back of the bed and starting pushing at 1:05pm, before the consultant and OB and midwives even got there.

I could hear people slowly arriving with someone shouting "A leg's already out!" but I was just solely focused on what I needed to do. I told my husband he had two jobs: make sure I don't try to change positions and don't let anyone try to interfere with the baby during the birth. I was lucky to have a wonderful consultant whose calming presence really put me at ease. Apparently he was very experienced with breech births and even supports it!

As I pushed I could feel every part of her coming out, this was such a different experience in comparison to my first, there were no contractions in between pushes, it was just constant pushing with big breaths whenever I could get one in. The most intense thing I've ever gone through! Especially as we got to her neck, the midwife was commenting as each part was coming out and I could hear her saying ok there's no chin yet, and the consultant saying in his tranquil tone come on now the biggest push of your life. Our baby was born at 1:13pm, after 8 minutes of pushing, and I knew my instincts were right, she wanted to come the way she wanted which was feet first. Our baby's apgar scores were 8 & 9, she's perfect and healthy, born into a room full of applause and high spirits.

The more I looked into breech births the angrier I got at the medical model and system in general. I believe Western Australia is meant to be one of the worst places when it comes to supporting breech births and the lack of education around it. They should be looking at each individual case, present you with your options and give reasons as to why you would be a good or bad candidate for it. It's disappointing the lack of knowledge around breech birthdays and I hope that these doctors start to try and make a change.

30/11/2025

This is very interesting.

The impact of parity on uterine rupture in patients with and without a previous cesarean delivery: a retrospective analysis of risk variation in women with and without a previous cesarean delivery - Probability of uterine rupture by number of previous VBACs
This graph illustrates the probability of uterine rupture during vaginal delivery attempts in women with 1 previous cesarean delivery, stratified by the number of previous VBACs. The x axis represents the number of previous VBACs (0 to≥5), and the y axis shows the corresponding rupture rate. Women with no previous VBAC had a uterine rupture risk of 0.64%. This risk decreased to 0.28% after 1 previous VBAC and continued to decline with additional VBACs, reaching 0.18% among those with 4 VBACs. Notably, no cases of uterine rupture were observed in women with 5 or more previous VBACs. A logistic regression analysis demonstrated a statistically significant inverse association between the number of previous VBACs and the risk for uterine rupture (P

11/11/2025

🌍 𝗡𝗲𝘄 𝗪𝗛𝗢 𝗚𝘂𝗶𝗱𝗲𝗹𝗶𝗻𝗲𝘀 𝗼𝗻 𝗣𝗿𝗲𝘃𝗲𝗻𝘁𝗶𝗻𝗴 𝗣𝗼𝘀𝘁𝗽𝗮𝗿𝘁𝘂𝗺 𝗛𝗮𝗲𝗺𝗼𝗿𝗿𝗵𝗮𝗴𝗲 (𝗣𝗣𝗛)

The World Health Organisation has released its 𝟮𝟬𝟮𝟱 𝗖𝗼𝗻𝘀𝗼𝗹𝗶𝗱𝗮𝘁𝗲𝗱 𝗚𝘂𝗶𝗱𝗲𝗹𝗶𝗻𝗲𝘀 𝗳𝗼𝗿 𝘁𝗵𝗲 𝗣𝗿𝗲𝘃𝗲𝗻𝘁𝗶𝗼𝗻, 𝗗𝗶𝗮𝗴𝗻𝗼𝘀𝗶𝘀 𝗮𝗻𝗱 𝗧𝗿𝗲𝗮𝘁𝗺𝗲𝗻𝘁 𝗼𝗳 𝗣𝗼𝘀𝘁𝗽𝗮𝗿𝘁𝘂𝗺 𝗛𝗮𝗲𝗺𝗼𝗿𝗿𝗵𝗮𝗴𝗲, and there’s one section that really caught my attention in the 𝘐𝘯𝘵𝘳𝘢𝘱𝘢𝘳𝘵𝘶𝘮 𝘪𝘯𝘵𝘦𝘳𝘷𝘦𝘯𝘵𝘪𝘰𝘯𝘴 𝘵𝘰 𝘱𝘳𝘦𝘷𝘦𝘯𝘵 𝘱𝘰𝘴𝘵𝘱𝘢𝘳𝘵𝘶𝘮 𝘩𝘢𝘦𝘮𝘰𝘳𝘳𝘩𝘢𝘨𝘦 section.

It says:

“Effective management of labour ensures timely interventions, 𝗮𝘃𝗼𝗶𝗱𝘀 𝗶𝗻𝗱𝘂𝗰𝘁𝗶𝗼𝗻 𝗼𝗿 𝗮𝘂𝗴𝗺𝗲𝗻𝘁𝗮𝘁𝗶𝗼𝗻 𝗼𝗳 𝗹𝗮𝗯𝗼𝘂𝗿 𝗼𝗿 𝗲𝗽𝗶𝘀𝗶𝗼𝘁𝗼𝗺𝘆 𝘄𝗵𝗲𝗿𝗲 𝗻𝗼𝘁 𝗰𝗹𝗶𝗻𝗶𝗰𝗮𝗹𝗹𝘆 𝗶𝗻𝗱𝗶𝗰𝗮𝘁𝗲𝗱, and generally fosters a supportive environment for quality intrapartum care.”

OBs and hospital policies are often quick to promote active management of the third stage of labour to prevent PPH, but how often do they ensure that 𝗶𝗻𝗱𝘂𝗰𝘁𝗶𝗼𝗻, 𝗮𝘂𝗴𝗺𝗲𝗻𝘁𝗮𝘁𝗶𝗼𝗻, 𝗮𝗻𝗱 𝗲𝗽𝗶𝘀𝗶𝗼𝘁𝗼𝗺𝘆 are avoided unless truly necessary to prevent PPH?

I want to really highlight the recommendation on episiotomies.

The guidelines also make this clear:

𝗥𝗲𝗰𝗼𝗺𝗺𝗲𝗻𝗱𝗮𝘁𝗶𝗼𝗻 𝟲:
“Routine or liberal use of episiotomy is 𝗻𝗼𝘁 𝗿𝗲𝗰𝗼𝗺𝗺𝗲𝗻𝗱𝗲𝗱 for women undergoing spontaneous vaginal birth.”

The WHO Guideline Development Group went even further, acknowledging both “𝘵𝘩𝘦 𝘭𝘢𝘤𝘬 𝘰𝘧 𝘦𝘷𝘪𝘥𝘦𝘯𝘤𝘦 𝘰𝘯 𝘵𝘩𝘦 𝘦𝘧𝘧𝘦𝘤𝘵𝘪𝘷𝘦𝘯𝘦𝘴𝘴 𝘰𝘧 𝘦𝘱𝘪𝘴𝘪𝘰𝘵𝘰𝘮𝘺 𝘪𝘯 𝘨𝘦𝘯𝘦𝘳𝘢𝘭” and that “𝘵𝘩𝘦𝘳𝘦 𝘪𝘴 𝘯𝘰 𝘦𝘷𝘪𝘥𝘦𝘯𝘤𝘦 𝘤𝘰𝘳𝘳𝘰𝘣𝘰𝘳𝘢𝘵𝘪𝘯𝘨 𝘵𝘩𝘦 𝘯𝘦𝘦𝘥 𝘧𝘰𝘳 𝘢𝘯𝘺 𝘦𝘱𝘪𝘴𝘪𝘰𝘵𝘰𝘮𝘺 𝘪𝘯 𝘳𝘰𝘶𝘵𝘪𝘯𝘦 𝘤𝘢𝘳𝘦.”

While I’m sure no maternity care provider would admit to a policy of “routine” episiotomies, some are certainly liberal with them.
In 2023 in Australia, 𝟮𝟮% 𝗼𝗳 𝗳𝗶𝗿𝘀𝘁-𝘁𝗶𝗺𝗲 𝗺𝗼𝘁𝗵𝗲𝗿𝘀 having a 𝘯𝘰𝘯-𝘪𝘯𝘴𝘵𝘳𝘶𝘮𝘦𝘯𝘵𝘢𝘭 𝘷𝘢𝘨𝘪𝘯𝘢𝘭 𝘣𝘪𝘳𝘵𝘩 received an episiotomy.
(Source: Australian Institute of Health and Welfare, National Core Maternity Indicators 2025)

So if there’s 𝗻𝗼 𝗲𝘃𝗶𝗱𝗲𝗻𝗰𝗲 𝗼𝗳 𝗯𝗲𝗻𝗲𝗳𝗶𝘁, and global guidance actively discourages it, why is it still happening so often?

Interestingly, while the WHO 2025 guidelines reaffirm that routine or liberal episiotomy is not recommended, they did continue to support the practice of “hands-on” perineal guarding to help reduce perineal trauma, even though the evidence for its effectiveness is uncertain.

The GDG noted that:

“Although the evidence on the effect of a hands-on approach (guarding) on reducing perineal tears is uncertain, it is unlikely to cause harm, requires minimal resources, may reduce traumatic injury, and is already embedded in clinical practice. In the absence of evidence of harm, the existing recommendation on this technique should be maintained.”

In other words, even with limited evidence, this technique is seen as acceptable because it might help and probably doesn’t harm. (𝘐 𝘥𝘰 𝘸𝘰𝘯𝘥𝘦𝘳 𝘪𝘧 𝘣𝘪𝘳𝘵𝘩𝘪𝘯𝘨 𝘸𝘰𝘮𝘦𝘯 𝘳𝘦𝘢𝘥𝘪𝘯𝘨 𝘵𝘩𝘦 𝘦𝘷𝘪𝘥𝘦𝘯𝘤𝘦 𝘸𝘰𝘶𝘭𝘥 𝘬𝘦𝘦𝘱 𝘵𝘩𝘦 𝘩𝘢𝘯𝘥𝘴-𝘰𝘯 𝘢𝘱𝘱𝘳𝘰𝘢𝘤𝘩 𝘪𝘯 𝘵𝘩𝘦 𝘨𝘶𝘪𝘥𝘦𝘭𝘪𝘯𝘦𝘴 🤔).

Episiotomy, on the other hand, is a 𝘀𝘂𝗿𝗴𝗶𝗰𝗮𝗹 𝗶𝗻𝗰𝗶𝘀𝗶𝗼𝗻 with potential for harm (including increasing PPH risk), so the decision to discourage its routine and liberal use shows that the WHO GDG considered the balance of benefit and risk and found that routine and liberal episiotomy does more harm than good.

If we’re genuinely committed to preventing postpartum haemorrhage, we need to look beyond active management of the third stage.

We need to make sure the 𝗳𝗶𝗿𝘀𝘁 𝗮𝗻𝗱 𝘀𝗲𝗰𝗼𝗻𝗱 𝘀𝘁𝗮𝗴𝗲𝘀 𝗼𝗳 𝗹𝗮𝗯𝗼𝘂𝗿 𝗮𝗿𝗲 𝗻𝗼𝘁 𝗼𝘃𝗲𝗿-𝗺𝗮𝗻𝗮𝗴𝗲𝗱, avoiding unnecessary inductions, augmentations, and yes, episiotomies.

🤱 𝗪𝗵𝗮𝘁’𝘀 𝗠𝗶𝘀𝘀𝗶𝗻𝗴

One thing that disappoints me about the new WHO 2025 PPH Guidelines is the complete absence of any mention of the role of 𝘀𝗸𝗶𝗻-𝘁𝗼-𝘀𝗸𝗶𝗻 𝗰𝗼𝗻𝘁𝗮𝗰𝘁 in supporting a physiological third stage and reducing PPH risk.

A 2023 scoping review by Ruiz et al. (𝘔𝘢𝘵𝘦𝘳𝘯𝘢𝘭 𝘢𝘯𝘥 𝘊𝘩𝘪𝘭𝘥 𝘏𝘦𝘢𝘭𝘵𝘩 𝘑𝘰𝘶𝘳𝘯𝘢𝘭, 27:582–596) highlighted the 𝗽𝗿𝗼𝘁𝗲𝗰𝘁𝗶𝘃𝗲 𝗿𝗼𝗹𝗲 𝗼𝗳 𝗲𝗮𝗿𝗹𝘆 𝘀𝗸𝗶𝗻-𝘁𝗼-𝘀𝗸𝗶𝗻 𝗰𝗼𝗻𝘁𝗮𝗰𝘁 𝗱𝘂𝗿𝗶𝗻𝗴 𝘁𝗵𝗲 𝘁𝗵𝗶𝗿𝗱 𝘀𝘁𝗮𝗴𝗲 𝗼𝗳 𝗹𝗮𝗯𝗼𝘂𝗿 through oxytocin release, uterine contraction, and stabilisation of maternal physiology. The authors concluded that this simple, low-cost practice may help prevent excessive blood loss after birth.

It is surprising that, while the WHO 2025 PPH guideline is so thorough in pharmacological and procedural interventions, it overlooks this evidence, even though 𝘀𝗸𝗶𝗻-𝘁𝗼-𝘀𝗸𝗶𝗻 𝗰𝗼𝗻𝘁𝗮𝗰𝘁 𝗶𝘀 𝗱𝗲𝘀𝗰𝗿𝗶𝗯𝗲𝗱 𝗯𝘆 𝗪𝗛𝗢 𝗶𝘁𝘀𝗲𝗹𝗳 𝗮𝘀 “𝘀𝗶𝗺𝗽𝗹𝗲, 𝗯𝘂𝘁 𝗹𝗶𝗳𝗲𝘀𝗮𝘃𝗶𝗻𝗴” in its 2022 𝘙𝘦𝘤𝘰𝘮𝘮𝘦𝘯𝘥𝘢𝘵𝘪𝘰𝘯𝘴 𝘰𝘯 𝘔𝘢𝘵𝘦𝘳𝘯𝘢𝘭 𝘢𝘯𝘥 𝘕𝘦𝘸𝘣𝘰𝘳𝘯 𝘊𝘢𝘳𝘦 𝘧𝘰𝘳 𝘢 𝘗𝘰𝘴𝘪𝘵𝘪𝘷𝘦 𝘗𝘰𝘴𝘵𝘯𝘢𝘵𝘢𝘭 𝘌𝘹𝘱𝘦𝘳𝘪𝘦𝘯𝘤𝘦, where 𝗶𝗺𝗺𝗲𝗱𝗶𝗮𝘁𝗲 𝗮𝗻𝗱 𝘂𝗻𝗶𝗻𝘁𝗲𝗿𝗿𝘂𝗽𝘁𝗲𝗱 𝘀𝗸𝗶𝗻-𝘁𝗼-𝘀𝗸𝗶𝗻 is promoted as standard care for all mothers and babies.

Because the best way to protect women from complications after birth is to 𝗽𝗿𝗼𝘁𝗲𝗰𝘁 𝗽𝗵𝘆𝘀𝗶𝗼𝗹𝗼𝗴𝗶𝗰𝗮𝗹 𝗯𝗶𝗿𝘁𝗵 𝗶𝘁𝘀𝗲𝗹𝗳 and then keep promoting physiology after birth.

These consolidated guidelines focus on the care of women during pregnancy, childbirth and the immediate postpartum period in any health care setting.

10/11/2025

✨ New research alert ✨
A new paper currently in press with the American Journal of Obstetrics & Gynecology (Edwards et al., 2025) explores how body mass index (BMI) influences labour progression,and the findings are important.

💡 Conclusion:
“Higher body mass index was associated with slower labor progress and longer labor duration in patients ultimately undergoing vaginal delivery. This difference was driven by longer times spent in latent labor, with no significant differences observed in active labor. Results suggest a potential need for the use of labor curves more specifically tailored to body mass index when assessing for progress in labor, in order to avoid performance of unnecessary cesarean deliveries.”

In plain terms: some bodies simply labour differently. Longer doesn’t mean abnormal, unsafe, or failing to progress. When we use a one-size-fits-all “textbook” timeline, we risk unnecessary interventions and lose sight of physiological variation.

🤍 What matters most:
• Individualised care, not clock-watching.
• Recognising that labour diversity = body diversity.
• Updating guidelines and labour charts to reflect this.

📚 For parents navigating pregnancy with a higher BMI, Dr Sara Wickham’s book "Plus Size Pregnancy" is an excellent resource for understanding your options and navigating hospital policies around BMI. sarawickham.com

https://www.sarawickham.com/plus-size-pregnancy/

06/11/2025

Who Decides About Fetal Monitoring in Labour?

I have just read the new RANZCOG Intrapartum Fetal Surveillance Guideline (2025). I can’t wait to hear what Dr Kirstin Small Birth Small Talk makes of them, but for me, two things really stand out:

1. The lack of evidence that continuous CTG improves outcomes when compared with intermittent monitoring.
2. The clear message that monitoring during labour should be guided by informed consent (but is this just lip service?).

Let’s talk about that first one.

The guideline cites plenty of studies showing associations between certain conditions and risk factors, but it doesn’t provide clear evidence that CTG use actually reduces those risks or improves outcomes.

There seems to be a real conflict between what the evidence shows and what the recommendations actually say.

The clinical algorithm says that if a risk factor is present, use continuous CTG.

But the answer to Clinical Question 5 —

“Which method of intrapartum fetal surveillance should be recommended in the presence of, or with emergence of, fetal and/or maternal risk factors during labour?” clearly states that there is little or no difference in outcomes between intermittent auscultation and continuous CTG, except that continuous CTG increases caesarean section rates.

And the answer to Clinical Question 6, "Accuracy of CTG in the diagnosis of fetal compromise", was "No single feature of a CTG performs well in predicting fetal compromise, with a large number of false positive results.

So if CTG doesn’t reliably predict fetal compromise and increases the likelihood of surgical birth without improving outcomes…
why does the algorithm still default to continuous CTG every time a risk factor appears?

That's because these are consensus-based recommendations, and consensus often reflects the biases and priorities of those making the recommendations.

As part of their consensus-based Evidence-to-Decision making framework, RANZCOG used the domain of Acceptability to help shape recommendations.

But it’s important to note,this isn’t about whether women find CTG acceptable. It’s about clinician acceptability.

For example, the guideline states:

“Continuous CTG is the standard care for intrapartum monitoring of women with high-risk births. This recommendation is consistent across the guidelines from all major Obstetric and Midwifery colleges and in state/district health board policies, thus it is expected the CTG use in labours for women with risk factors will be acceptable to clinicians.”

It really makes me wonder, what if you gave a group of consumers (the women and families who actually experience birth) the same evidence? What would their consensus-based recommendations look like?
Would they also say, “Let’s hook everyone up to a machine that limits movement and increases intervention rates, even though it hasn’t been shown to improve safety”?
Or would they say, “Let’s keep women free to move, rest, and follow their instincts, while checking in regularly and respectfully”?

I do like that the guidelines highlight that clinicians have a responsibility to explain the advantages and disadvantages of different types of fetal monitoring so that women can make an informed decision and give valid consent.

However, the clinical algorithm doesn’t include any pathway for women who decline continuous monitoring.
It only gives instructions for what to do if a risk factor is identified, assuming CTG will follow.

Yes, the document does say that:

“Women’s decisions regarding fetal surveillance should not affect the level of general care and support provided in labour.”

That’s an important statement.
But the algorithm itself doesn’t reflect that principle. There’s no branch that says, “If the woman declines CTG, continue with intermittent auscultation and supportive care.”

Instead, there’s an overarching assumption that women will consent, that “informed consent” means eventual agreement.
But true consent includes the right to say no, and to have that decision respected without consequences, guilt, or withdrawal of support.

One of the "Guiding Principles of Care" listed in the guideline includes the provision of woman-centred care.
But reading through the recommendations, it’s hard not to feel that RANZCOG still doesn’t really understand what that means.

True woman-centred care starts from the woman’s experience, her values, her body, her safety, her choices and builds care around her, not just clinician comfort
These guidelines still built around risk, surveillance, and control.