Title Guideline consultation generates inevitable challenges but invaluable communication SignatoryPauline McDonagh Hull, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, CanadaLetterDear Sir, As first author of one of the BJOG letters cited in Dr. Murphy’s commentary on the ‘unwelcome consequences of guideline authorship’1 (‘Montgomery is missing from RCOG’s Assisted Vaginal Birth guideline’),2 and director of one of the organisations that submitted comments during the Royal College of Obstetricians and Gynaecologists’ consultation, I would appreciate the opportunity to clarify my involvement and position in the matters described, to avoid potential misinterpretations or assumptions where individuals and organisations have not been named. Dr. Murphy mentions ‘individuals who…believe that forceps should be abolished entirely’, and informs readers this view ‘was reflected in one submission…from a patient advocacy organisation who suggested that planned caesarean section should be recommended to women as a means of avoiding AVB.’ She then notes that our Montgomery letter2 ‘repeated the same point about planned caesarean section they had made during the consultation process.’ For the record, the submission from my voluntary organisation, Caesarean Birth, did not suggest forceps should be abolished, and proposed offering, not recommending, planned caesareans. I disagree with Dr. Murphy’s assertion that our letter was ‘hostile’, and we stand by the concerns expressed therein. However, where I do agree with Dr. Murphy is in relation to the irrefutable challenge ‘of reconciling polarised views’. While our criticism of the RCOG guideline may be perceived as ‘an agenda’ to ‘undermine authors’, it may also be perceived as a sincere effort to influence a hegemonic shift in maternity services in the face of unprecedented maternity litigation resulting from avoidable harm. These views may never be fully reconciled, but I believe we all share the same goal of improving health outcomes. Moreover, the RCOG has responded to criticism of its assisted vaginal birth and caesarean birth recommendations in the past; initially removing them from its website temporarily, and then permanently, five years later.3Last year, the University of Aberdeen was awarded almost 1 million GBP to develop a novel decision aid, to be offered to all women, for planning mode of birth.4 In my view, the option of planned caesarean birth should not be reserved for obstetricians or women who initiate discussions, as this does not constitute equitable care. Language in maternity services is changing too. While Dr. Murphy refers to ‘caesarean section’, both the RCOG and National Institute for Health and Care Excellence (NICE) adopted ‘caesarean birth’ for their respective 2021 guideline and 2022 Considering a caesarean birth publications. Finally, when Dr. Murphy highlights the lack of remuneration for guideline authors, she echoes my own experience of countless hours in unpaid consultation; barring one significant difference. Only authors have the privilege of determining the final version. We also concur on the importance of providing stakeholders the opportunity for public debate. Prior to reading Dr. Murphy’s commentary, I was not aware of the complaint she received, and certainly support individual safeguarding as we all navigate the inevitable disagreements ahead. Nevertheless, open channels of communication and consultation remain a valuable and indispensable method to examine, and in some cases disrupt, established ways of thinking, and they must not be diminished.References1. Murphy DJ. The unwelcome consequences of Guideline authorship. BJOG 2023;00:1-2. 2. McDonagh Hull PM, Thomas K, Skinner E, Dawes A, Christensen P. Re: assisted vaginal birth: green-top guideline no. 26: Montgomery is missing from RCOG’s assisted vaginal birth guideline. BJOG2020;127(10):1297–8. 3. Weston N. Making sense of commissioning Maternity Services in England – some issues for Clinical Commissioning Groups to consider . Royal College of Obstetricians and Gynaecologists, 14 August 2012. 4. Scientists awarded £1million to help women make childbirth choices. University of Aberdeen, 27 September 2022. https://www.abdn.ac.uk/news/16386/. Accessed 5 June 2023.

Just weeks following the fifth anniversary of the landmark Montgomery v Lanarkshire Health Board Supreme Court judgment, the Royal College of Obstetricians and Gynaecologists (RCOG) has delivered the fourth edition of its Green-top guideline on forceps and vacuum assisted births1. The irony of this is not lost on those who expected real change following last year’s peer review consultation (19 physicians and 6 maternity care organisations responded, including the first two signatories of this letter). The guideline opens with a fundamental question: Can assisted vaginal birth be avoided? The answers RCOG provides are solely in the context of labour (evidence on continuous support, epidural analgesia, positions adopted, delayed pushing), but a legal interpretation of Montgomery advises birth is “a situation that allows for significant advance planning and accordingly plans must be made.”2 The guideline concurs: women “should be informed about assisted vaginal birth in the antenatal period, especially during their first pregnancy [and] in advance of labour”. Nevertheless, while “lower rates in midwifery-led care settings” is included, ‘lower rates with planned caesarean’ is not, and there is no direct equivalent Green-top for this birth mode. The Montgomery judgment on consent specifically states that doctors are “under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments.” It also emphasises that in any pregnancy, the “principal choice is between vaginal delivery and caesarean section.” RCOG may argue that referencing the “alternative choice of a caesarean section late in the second stage of labour” sufficiently addresses these points. However, a Queen’s Counsel who was involved in the Montgomery case reminds doctors that the mother “was not advised that an alternative to vaginal birth (i.e. caesarean section) was an option available to her… and there was an increased risk… should vaginal birth be attempted.”2 He warns, “Where the patient asks a question, it must be answered honestly and fully”, which suggests that planned caesarean birth omission from this Green-top could have serious legal consequences, and there is every chance the Montgomery case could reoccur.Despite aiming “to provide evidence-based recommendations”, RCOG does not include pelvic organ prolapse as an adverse outcome. Instead, it says women who “achieve an assisted vaginal birth rather than have a caesarean birth… are far more likely to have an uncomplicated vaginal birth in subsequent pregnancies”, and that “much of the pelvic floor morbidity reported… may not be causally related to the procedure.” Furthermore, the stated aim of RCOG’s clinical Green-tops is to identify “good practice and desired outcomes”, which will be “used globally.”4 This is relevant because many countries define this as low caesarean birth rates. In the UK, the National Institute for Health and Care Excellence (NICE) does not advocate targets, and recommends support for prophylactic caesarean birth requests.3 Yet decades of promoting vaginal birth rather than informed choice has obstructed autonomy and contributed substantially to rising litigation costs.5The truth is, the NHS simply cannot afford to keep repeating the same communication and consent mistakes, and in our view, this NICE accredited Green-top guideline clearly demonstrates that lessons from Montgomery have still not been learned.Pauline M Hull, Founder, Caesarean BirthKim Thomas, CEO, Birth Trauma OrganisationDr. Elizabeth Skinner, Faculty of Medicine, University of SydneyAmy Dawes, Co-founder and CEO, Australasian Birth Trauma AssociationPenny Christensen, Executive Director, Birth Trauma Canada