Maternity Guidelines Aren’t Rules: What Does That Actually Mean for You?

During pregnancy, birth and the postnatal period, you'll probably come across maternity guidelines more than once.

You might be told:

“Because you've had a previous caesarean, the guidance recommends…”

“Because of your age, we would usually offer…”

“Because of your BMI, our recommendation is…”

“Our guideline is…”

“Our policy says…”

When you're sitting in an appointment, particularly if you're being told that something you had hoped for isn't recommended, it can sometimes sound as though the conversation has already been decided for you.

But a guideline isn't quite the same thing as a rule.

And understanding the difference can make it much easier to take part in decisions about your maternity care.

What is a maternity guideline?

Clinical guidelines are there for an important reason.

They bring together the best available evidence and expert consideration to help healthcare professionals make safe, consistent and evidence-based recommendations about care.

NICE, the National Institute for Health and Care Excellence, produces many of the guidelines used throughout maternity care in England. The Royal College of Obstetricians and Gynaecologists (RCOG) also produces clinical guidance and patient information relating to pregnancy and birth.

As an independent midwife, I use guidelines too.

They help inform my clinical judgement, the conversations I have with women and the recommendations I make.

But guidelines still need to be applied to the individual woman receiving care.

You are not a guideline.

You are a person with your own medical and pregnancy history, circumstances, preferences, previous experiences and feelings about what matters to you.

Good maternity care brings those things together.

A recommendation isn't the same as consent

This is probably one of the most important things to understand.

A healthcare professional can recommend something because they genuinely believe it is the safest or most appropriate option for you.

That recommendation matters.

But recommending an intervention and giving consent for it are two different things.

Current NICE antenatal guidance says that when an assessment, intervention or procedure is offered, the benefits, risks and implications should be discussed with the woman and she should be made aware of her right to decline.

NICE also makes clear that a woman's decision should be respected, even when it differs from the view of the healthcare professional.

The Nursing and Midwifery Council (NMC), which regulates midwives in the UK, is equally clear about informed consent. The NMC Code requires midwives to obtain properly informed consent and to respect, support and document a person's right to accept or refuse care and treatment.

The NMC's Principles for Supporting Women's Choices in Maternity Care also specifically address situations where women make choices outside standard care pathways or decline recommended care.

So informed choice isn't simply a nice extra when there's enough time for a conversation.

It is part of professional maternity care.

What does shared decision making actually look like?

Shared decision making means that you and the healthcare professional looking after you bring different things to the conversation.

They bring clinical knowledge, experience, evidence and an understanding of the potential benefits and risks of the available options.

You bring something equally important: you.

You know your experiences, priorities, values, circumstances and what matters to you.

NICE describes shared decision making as a collaborative process between a person and their healthcare professional. It includes discussing the available options and their possible benefits, risks and consequences, including the option of not having a treatment or not changing the current plan.

It shouldn't simply be: “This is what we do.”

It should be a conversation.

“But it's hospital policy…”

You might sometimes hear a recommendation described as hospital or Trust policy.

Policies and clinical guidelines are important. They help organisations provide consistent care and give healthcare professionals frameworks within which to practise safely.

But a policy doesn't replace the process of informed decision making.

You can still ask why something is being recommended, how the recommendation applies to your individual circumstances and what alternatives are available.

RCOG's consent guidance reflects the same principles. Healthcare professionals should explain recommended management, discuss the risks and implications of the available options, talk about alternatives and explain the possible consequences of not having a proposed treatment or intervention.

Where circumstances allow, women should also have access to good-quality information and adequate time to consider their decision.

What questions can I ask?

If somebody recommends something during your pregnancy or birth and you aren't sure why, it's completely reasonable to ask questions.

You might ask:

Why are you recommending this for me?

What are the benefits?

What are the possible risks?

What are my alternatives?

What could happen if I wait?

What could happen if I decide not to have it?

How does this evidence apply to my individual circumstances?

Do I need to make this decision now?

Sometimes you'll hear people use decision-making tools such as BRAIN, which stands for Benefits, Risks, Alternatives, Intuition and Nothing or Next.

You don't have to remember an acronym, though.

The important thing is that you understand enough about your options to participate meaningfully in the decision.

Understanding risk matters too

The way risk is explained can make an enormous difference to how information feels.

Being told that something “doubles the risk”, for example, can understandably sound frightening.

But there's a big difference between a risk increasing from 1 in 1,000 to 2 in 1,000 and increasing from 20 in 100 to 40 in 100, even though both could be described as doubling.

NICE recommends using absolute rather than relative risk where numerical information is available, as well as presenting information in ways that help people understand both positive and negative outcomes.

So if you're given a percentage or told that something increases your risk, you can ask:

“What does that mean in actual numbers?”

That can make the information much easier to understand.

Choosing outside a guideline doesn't mean choosing without care

Sometimes, after discussing the evidence, benefits, risks and alternatives, a woman makes a decision that sits outside a standard recommendation.

That doesn't mean the conversation about safety stops.

In fact, this is where individualised care becomes particularly important.

What additional monitoring might be appropriate?

Are there ways of reducing particular risks?

What would make us reconsider the plan?

What signs or symptoms would mean seeking help?

What is the plan if circumstances change?

Who else needs to be involved?

A decision made today also doesn't necessarily have to remain the decision tomorrow.

Pregnancy and birth aren't static. Circumstances change, new information becomes available and sometimes what felt right at 30 weeks feels different at 38 weeks or during labour.

Changing your mind is allowed.

Guidelines and individualised care can exist together

I sometimes think discussions around maternity choices get presented as though there are only two positions.

You either “follow the guidelines” or you reject them.

I don't see it that way.

Guidelines and evidence are incredibly important. They help us understand outcomes, recognise risk and make recommendations about safe care.

But individualised care matters too.

My role as a midwife isn't to withhold information because I think it might influence your decision, nor is it to pretend a risk doesn't exist because you would prefer a particular option.

It is to give you honest, evidence-based information, explain what I'm recommending and why, answer your questions, listen to what matters to you and continue assessing your individual circumstances.

Sometimes, after that conversation, your decision will be exactly what the guideline recommends.

Sometimes it may not be.

Either way, you should understand the decision you're making and feel that you've genuinely been part of making it.

Because good maternity care isn't about blindly following every recommendation.

And it isn't about automatically rejecting one either.

It's about understanding the evidence, understanding your individual circumstances and having a meaningful conversation about what that means for you.

That, to me, is informed choice.