By Dr Ellie Rayner, Obstetrician & Gynaecologist
In the UK, as part of the NHS there are two main models of care: midwife-led care and consultant-led care. At your first, or ‘booking’ appointment with your midwife you will be asked lots of questions to determine whether you are at low or higher risk of complications during your pregnancy and whether referral to an Obstetrician, a doctor who specialises in pregnancy, labour and birth, is recommended. There are many different reasons why this might be advised, and I will cover some of the most common and most important occasions here and the differences between these two models of care.
At the booking appointment your midwife will take a detailed medical, social and family history, including asking for information on any previous pregnancies and any medications you are currently taking.
- ✳️ If it is your first pregnancy and you have conceived spontaneously, are normally fit and well, have no underlying medical problems, have a normal body mass index (BMI) and are not taking any regular medication (except pregnancy supplements) you are likely to be deemed low-risk of complications and be eligible for Midwifery-led-Care, usually comprising of up to 10 antenatal appointments.
- ✳️ If you have a baby before, your midwife will ask you about the events of your previous pregnancy, whether you developed any complications and ask in detail about your labour such as, whether you were induced, the type of birth you had and how your recovery was. If you have had a previously uncomplicated pregnancy and birth and have developed no new medical issues or problems since your last baby, you will likely be recommended Midwifery-led care and usually had around 7 antenatal appointments this time.
If you are booked for Midwifery-led care all of your antenatal appointments, your planned labour and birth care and postnatal follow-up will all be with a midwife as your lead professional. All birth-place options will usually be available for you including home birth, midwife led unit or consultant-led unit. These appointments may be provided at home, in the community, at your GP surgery or local maternity hospital but if all remains well, you will not meet a doctor during your pregnancy journey.
If you have certain medical problems or have had complications in a previous pregnancy, your midwife will refer you for Consultant-led care to the Antenatal Clinic for a Doctors’ opinion. Sometimes, this may be by writing a letter asking for advice, but more commonly an appointment will be made for you to attend your local maternity hospital for review either at around 12 or 20 weeks of pregnancy. Depending on the reason for the referral, if after reviewing your individual circumstances they are happy that there is no reason your pregnancy is at higher risk of complications, the Obstetrician may revert your care back to midwife-led. This means the remainder of your appointments and antenatal/postnatal care will be with your midwifery team.
Depending on your circumstances and the reason for the referral, the Obstetrician may not need to see you again, but may make further recommendations for your pregnancy, such as additional appointments with your midwife, or may recommend birthing at the hospital if they are concerned about a complication arising during labour. They will discuss in detail their recommendation with you and why and will document an agreed plan in your maternity notes. If this is the case, even though you are not seeing the Obstetrician again, you will still remain under the care of a named Consultant.
If your pregnancy is more complex, your Obstetrician may recommend additional monitoring of you or your baby throughout your pregnancy, such as additional growth scans, blood tests or appointments, or referral to another specialist with more experience looking after women in your situation. These appointments are likely to be at your local maternity hospital and are usually in addition to the routine midwife appointments all women have, but not always.
What are the most common reason for referral for advice?
- ✳️ Pre-existing medical problems – such as Asthma, Diabetes, High Blood Pressure or Epilepsy
- ✳️ High or low BMI – BMI <18 or a BMI >30
- ✳️ Age more than 40 years at conception
- ✳️ Fertility treatment – such as IVF or donor egg pregnancy
- ✳️ Multiple pregnancy – twins or triplets
- ✳️ Lifestyle factors – Smoking, drinking alcohol or using recreational drugs at conception and during pregnancy
- ✳️ Complications in a previous pregnancy – such as preeclampsia, previous small baby or previous pregnancy loss
- ✳️ Previous labour complications – such as shoulder dystocia, heavy bleeding after birth, third- or fourth-degree tear or previous Caesarean Section.
What happens if something changes during my pregnancy?
It is not uncommon for women to develop new issues during pregnancy that might mean you are recommended to transfer from midwifery to consultant-led care. Developing conditions such as pregnancy diabetes (gestational diabetes), high blood pressure, preeclampsia or obstetric cholestasis are common reasons your midwife may refer you for an Obstetric appointment. Additionally, if your midwife has any concerns over your baby’s growth, they may refer you for additional scans and/or appointments.
What will be discussed at the Obstetric appointment?
The Obstetrician will review your history in detail and discuss the reason for the referral and how your circumstances may impact your pregnancy. These are the four main topics that are commonly discussed:
- ✳️ Additional Monitoring - They will discuss any additional monitoring you are being offered, such as additional growth scans of your baby and the plan for follow-up throughout your pregnancy. They may recommend an induction of labour or a Caesarean Section instead of waiting for labour to start naturally.
- ✳️ Place of Birth - If an Obstetrician feels your labour may be at higher risk of complications, they may advise you deliver in a Consultant-led Unit, commonly known as a Labour Ward or Delivery Suite, for the safety of you and your baby. These units are overseen by a team of doctors and have an ability to monitor your baby continuous throughout labour and immediate facilities to perform an operative or surgical delivery, such as a Caesarean Section, if needed. Even if you are advised to birth on a labour ward, you will still be primarily cared for by a midwife throughout your labour and birth, with a doctor overseeing the process. Sometimes you may meet the Obstetrician covering the delivery suite, or they may attend your birth, but not necessarily if your labour is progressing as expected and the midwife has no concerns.
- ✳️Monitoring during Labour - The Obstetrician may recommend continuous foetal monitoring during your labour, rather than a midwife listening intermittently with a handheld doppler. This type of monitoring using a CTG (cardiotocography) machine is only possible in the Consultant-led unit.
- ✳️Postnatal Observation/follow-up - They also may recommend staying in hospital after birth to observe you or your baby if they feel either of you has a higher risk of problems in the immediate postnatal period.
All of these considerations are very individualised and are often not all discussed at one appointment. Often your Obstetrician will recommend seeing how your pregnancy evolves and give you time to consider your options, read some written information before making any final decisions together about your labour and birth.
Do I have a choice?
Absolutely, as with all aspects of pregnancy, labour and birth, it is ultimately your decision how you are cared for during pregnancy and birth and you do not have to accept anything you don’t want to. All appointments and advice are recommendations, and your midwife and doctor will explain in full their rationale for the additional monitoring or advice and the pros and cons of accepting or declining, but ultimately it is your choice about how your pregnancy is managed.
The two models of care are designed to ensure that women have the appropriate care for them and their baby to reduce their risk of complications. Studies have shown that if you are healthy with no risk factors for developing complications, midwife-led care is safe and associated with less intervention in labour and birth.
If you have any questions or concerns at any point in your pregnancy journey or are unsure about something do speak to your healthcare team as they will be happy to explain things for you or direct you to a recognised resource for further information.
About the Author
Dr Ellie Rayner, Obstetrician and Gynaecologist, Antenatal and Hypnobirthing Teacher and founder of The Maternity Collective.
Dr Ellie Rayner is a practicing Obstetrician and Gynaecologist and founder of The Maternity Collective. She is the only Obstetrician to offer private and group, expert-led Antenatal and Hypnobirthing Classes both Online and face-to-face. She is passionate about providing parent-centred, evidence-based care for all pregnancies and supports all methods of birth. Follow Dr Ellie Rayner @maternitymedic for the latest evidence-based information on pregnancy, birth and women’s health issues.
The Maternity Collective provide comprehensive online antenatal and birth preparation courses led by a team of NHS expert healthcare professionals, including a Community Midwife, Obstetrician, Internationally Board-Certified Lactation Consultant (IBCLC) and Newborn Sleep and Behaviour Expert. They offer a complete 7 hour online antenatal and birth preparation course that can undertaken from the safety of your own home, at your own pace with videos to re-watch as many times as needed. More information is available at https://www.thematernitycollective.co.uk/