Dogmas in Obstetrics: Evidence-Based Standards, Clinical Judgement and Patient-Centred Care

Abstract

Obstetrics requires standards, guidelines and established pathways to support physiological birth and to manage rare emergencies reliably. Standards become problematic, however, when they are detached from their evidentiary basis, original indication or individual clinical context and are applied as dogmas. This narrative review and conceptual analysis examines typical mechanisms of dogmatic decision-making in obstetrics: routine interventions without individual indication, seemingly precise thresholds, medico-legal safety routines, inconsistent definitions of obstetric complications, psychological norms of ‘correct’ birth, and reservations towards digital innovation. Selected examples include foetal monitoring in low-risk labour, amniotomy and episiotomy, shoulder dystocia, timing of cord clamping, induction of labour, antenatal corticosteroid administration, maternal autonomy and patient-reported outcome and experience measures. The analysis argues that modern obstetrics can be neither dogma-free nor rule-free. Instead, it requires a reflective balance of standardisation, clinical judgement, team competence, transparent communication and organisational learning. Less dogmatic obstetrics does not imply arbitrariness; it means consistently linking each routine to evidence, plausibility, context, resources and the informed preferences of the patient.

Introduction

Obstetrics is a speciality in which standards are essential. Without a common language, established procedures, defined escalation pathways and practised emergency protocols, it would not be possible to ensure the safety of both mother and child. Guidelines, clinical standards and checklists are therefore not obstacles to personalised obstetric care, but rather one of its prerequisites. They reduce variability where variability could be dangerous and provide consistency in situations where time, team coordination and experience are crucial.

At the same time, obstetrics operates within a particular area of tension: It supports a predominantly physiological process, but must be prepared at all times for emergencies that occur rarely, but are highly dynamic and potentially catastrophic. This tension gives rise to routines which are originally intended to provide protection but which, in everyday clinical practice, can take on a life of their own to the detriment of both mother and child.

A dogma, in the sense used here, is not merely an incorrect statement. Rather, what is meant is a rule, a threshold or a pattern of behaviour that is continued regardless of the evidence, context, indication and the patient’s preference. Dogmas in obstetrics are not simply the wrong rules. They frequently begin as reasonable standards: in response to a complication, as a way of simplifying teaching, as a legal safeguard, or as an attempt to make healthcare provision predictable in the face of scarce resources.

International and national guidelines now place greater emphasis than before on the importance of respectful, risk-adjusted and low-intervention care for physiological births 1 2 3 4 5 6 . At the same time, clinical reality shows that the implementation of such recommendations depends on staffing levels, liability considerations, team culture, documentation requirements and local healthcare structures. The crucial question, therefore, is not whether obstetrics needs standards, but rather how standards can be prevented from becoming dogmas when they are not regularly re-evaluated. Or, to put it another way: whether dogmas that have been accepted for decades should be allowed to persist.

Modern obstetric care is also under increasing structural pressure: Hospital closures, staff shortages, the move towards more academic qualifications for midwives, financial constraints, high levels of forensic scrutiny and changing expectations amongst patients. In such phases, there is an understandable tendency to cling to familiar practices. The more productive approach is to take the opposite tack: Identify clinical practices, assess the evidence underpinning them, weigh up the benefits and harms, and tailor them to the individual where such individualisation is clinically relevant.

The aim of this review is to describe recurring dogmatic patterns in obstetrics, to analyse their medical, ethical, psychological and organisational implications, and to propose a pragmatic framework for evidence-based, patient-centred and adaptive obstetrics.

Overview/Review

Methodological approach and conceptual framework

This article is structured as a narrative review and conceptual analysis. The review took into account key international and national guidelines, systematic reviews, ethical statements and selected original research papers on obstetric interventions, patient autonomy, the birth experience, foetal monitoring, shoulder dystocia, the timing of umbilical cord clamping, antenatal corticosteroid administration and the quality of care ( Table 1 ). A systematic literature search with a predefined protocol, quality assessment and meta-analysis was not performed; the literature was selected on a topic-by-topic basis and was guided by clinical relevance, the level of evidence in the guidelines and the plausibility of the reasoning.

Table 1 Examples of the transition from standard to dogma and possible countermeasures.

Subject area	Sensible standard	Dogmatic error	Corrective measure
CTG for low-risk pregnancies	Risk-adapted foetal monitoring	Continuous CTG as a standard safety procedure in routine practice	Criteria for intermittent auscultation, team training, documentation
Amniotomy	Induction of labour where there is a clear medical indication	Routine acceleration without context	Assessment of indications, identifiable benefits, risk of infection, informed consent
Episiotomy	Targeted implementation for a specific indication	Routine prophylaxis or complete taboo	Restrictive application, but not ideologically driven
Shoulder dystocia	Standardised emergency procedures	The ‘promise’ of prediction based on imprecise risk markers	Training, communication, documentation of inevitability
Antenatal corticosteroids	Administered if there is a high probability of preterm birth within seven days	Prophylactic administration in cases of non-specific or long-term risk; routine repeat doses	Assess the risk of premature birth, aim for the optimal time window, and reassess the indication before repeating the procedure
Cord clamping	Delayed cord clamping in stable newborns	Immediate cord clamping in compromised newborns without discussing the underlying pathophysiology	Check whether resuscitation is possible whilst the umbilical cord is still intact; assess whether this is feasible locally
Birth experience	Providing information and offering respectful support	The moral standard of the ‘right’ birth	Shared decision-making, the mother’s right to self-determination, debriefing, psychosocial sensitivity

The term ‘dogma’ is understood in an operational sense in what follows. An obstetric practice is considered dogmatic if it exhibits at least one of the following characteristics: firstly, routine application without individual indication; secondly, continued use despite changes in the evidence; thirdly, a confusion between guideline recommendations and a mandatory algorithm; fourthly, a seemingly precise threshold-based logic that fails to take biological variability into account; fifthly, communicative or moral standardisation that restricts patient autonomy; sixthly, an organisational rule whose rationale, or the structural cause underpinning it, is no longer transparently articulated.

This does not, however, imply any refusal to consent to standardisation. On the contrary: Standards are particularly important in situations where emergencies that occur rarely need to be managed reliably. Standardisation only becomes dogmatic when it is no longer justified, reviewed and applied in a manner appropriate to the situation.

Why obstetric dogmas arise

Obstetric dogmas rarely arise out of ignorance. They are often by-products of clinically understandable defence mechanisms. A single dramatic complication may lead to a particular intervention being used more widely in future. A traumatic experience that demands forensic investigation can alter the way an entire team perceives risk. Structural understaffing can lead to a preference for predictable, standardised processes over time-consuming, personalised approaches. In such an environment, it is understandable that routines continue unquestioned.

This makes evidence-based practice in obstetrics more complex than in many other clinical disciplines. Numerous relevant endpoints, for example maternal and neonatal deaths or serious morbidities, are rarely encountered, have multiple causes and cannot be randomised at will for ethical reasons (i.e. for ethical reasons alone, it is not possible to recruit patients for every research question – however interesting it may be). At the same time, maternal and neonatal safety, the subjective experience of childbirth, autonomy, the initiation of breastfeeding, pelvic floor function, mental health and the use of resources are weighted differently. Guidelines can help to structure these competing objectives, but they cannot resolve them completely.

Dogmas frequently fill precisely this gap. They reduce ambiguity, provide clarity on how to proceed and make documentation easier. The price they pay is that they can override clinical judgement, team reflection and patient preference.

Clinical routines: Indication rather than automatism

Classic examples of dogmatic routines include measures that were long considered plausible on the grounds of hygiene, to speed up labour or for preventive purposes: Shaving, enema, routine amniotomy, routine episiotomy, standardised supine position or guided pushing. Many of these practices are not fundamentally wrong; the problem lies in their automatic application. The key word is ‘routine’. An amniotomy may be advisable following a case-by-case assessment; an episiotomy may be indicated in certain situations; and cardiotocography (CTG) may be essential in high-risk situations. The measure only becomes dogmatic if it is performed without a valid indication.

The WHO recommendations on intrapartum care, the German S3 guideline on vaginal delivery at term, NICE recommendations and ACOG statements all emphasise the importance of a cautious, respectful and risk-adjusted intervention strategy during physiological births 1 2 3 4 5 6 . However, this does not imply a counter-dogma of avoiding intervention. The art of medicine lies in distinguishing between necessary intervention, helpful support and unnecessary routine procedures that are distressing for the pregnant woman.

This distinction is clinically challenging because it cannot be derived from statistics alone. It requires experience, situational awareness and a willingness to justify one’s usual practice. An obstetrics approach with few dogmas therefore does not ask: ‘Do we always do it like this?’ But rather: ‘What specific medical indication is there at present, what benefits can we expect, what risks are involved, and has the patient been adequately involved in the decision?’

Foetal monitoring: Evidence, accountability and local feasibility

Hardly any other example illustrates the tension between evidence and the reality of clinical practice as clearly as foetal monitoring. For specific low-risk situations, intermittent auscultation is an option in line with clinical guidelines 1 2 3 4 5 . Continuous CTG is associated with a lower rate of neonatal seizures compared with intermittent auscultation, but not with a proven reduction in perinatal mortality or cerebral palsy; at the same time, it increases the rate of caesarean sections and operative vaginal deliveries 7 . At the same time, continuous CTG monitoring is, in practice, the dominant standard in many clinics.

This dominance cannot be explained by medical evidence alone. Intermittent auscultation requires sufficient staff, a high level of professional expertise, structured documentation, clear escalation criteria and a strong relationship of trust between midwives and doctors. If these conditions are not met, continuous CTG is regarded as a more reliable solution from both an organisational and a forensic perspective. The real reason, then, lies not in the superiority of the method, but in the conditions under which it is applied.

A scientifically rigorous discussion must keep these levels separate. It is legitimate to opt for closer/continuous monitoring in a clinic, due to local organisational structures, so as not to miss the opportunity for early intervention (e.g. transfer to a perinatal centre). The problem arises when this decision is retrospectively characterised as being based solely on evidence. It would be equally problematic to posit intermittent auscultation as a universally superior practice, regardless of the team’s expertise and the availability of resources. Guidelines provide guidance; it is up to the clinical organisation to decide whether a recommendation in this regard can be safely implemented.

The mathematisation of childbirth: thresholds between guidance and false precision

Obstetrics necessarily works with thresholds: Gestational age, cervical findings, duration of labour, estimated foetal weight, amniotic fluid volume, blood loss, pH value, base excess, Apgar score. Such parameters are essential because they enable communication, progress monitoring and risk stratification. They become dogmatic when guiding principles give rise to decision-making mechanisms that appear precise but are in fact misleading.

The assessment of the timing of labour is one example. If a cervical dilatation of 8 cm is documented during a vaginal examination and full dilatation is found two hours later, it is unclear when the transition actually occurred. It is not possible to reconstruct physiological dynamics with mathematical precision from discontinuous observations. Nevertheless, in clinical routine, such intervals are sometimes treated as though precise times and fixed deadlines could be derived from them.

The same applies to the estimated foetal weight. Ultrasound-based estimates of foetal weight are clinically useful but have considerable variability. If decision-relevant cut-off values for caesarean section and induction indications, as well as for the prevention of shoulder dystocia, are derived from them, this results in ‘false precision’. The question is not whether thresholds may be used, but whether their uncertainty is taken into account and communicated.

Induction of labour and elective procedures: Population-based evidence and individual risk

The induction of labour illustrates another key conflict. Population-level evidence may show that, in certain populations, induction of labour is associated with favourable, or at least no less favourable, outcomes compared with expectant management.

The ARRIVE trial had a major influence on the international debate surrounding elective induction of labour in low-risk nulliparous women between 39+0 and 39+4 weeks’ gestation compared with expectant management 8 . At the same time, applying these data to individual patients and different healthcare systems remains challenging 9 : Whether this is because the patients refuse induction, or because the health system, in its current form, is unable to provide induction for every low-risk pregnant woman from 39+0 weeks of gestation onwards. On the other hand, assuming that the evidence remains unchallenged, it would be worth discussing in greater detail how it could nevertheless be applied in practice.

The prospective risk of intrauterine foetal death increases with advancing gestational age, but remains low in absolute terms (in the per mille range) 10 .

A recommendation for induction of labour must therefore take into account absolute risks, maternal preference, cervical readiness, parity, comorbidities, obstetric history, local resources and the quality of care. A dogmatic approach would be both the automatic induction of every pregnant woman and the categorical rejection of induction as ‘unnatural’. What is therefore required is an individual, case-by-case decision made jointly with the pregnant woman.

It is precisely here that the difference between evidence-based and protocol-based medicine becomes apparent. Evidence-based medicine integrates the best available data, clinical expertise and the patient’s values. Protocol-based medicine reduces this triad to compliance with a single rule. That’s not enough for obstetrics.

Antepartum corticosteroids: targeted treatment rather than routine prevention

In cases of a genuine risk of preterm birth, antenatal corticosteroid treatment is one of the most effective interventions in perinatal medicine. A single course of treatment reduces perinatal and neonatal mortality, neonatal respiratory distress syndrome and, in all likelihood, the risk of severe intraventricular bleeding 11 . However, the benefits depend crucially on there being a high probability that the premature birth will occur within the following seven days 12 13 . This is precisely where the risk of dogmatic overtreatment lies: Non-specific contractions, an isolated abnormal cervical finding or the mere possibility of a subsequent preterm birth are sometimes already regarded as sufficient grounds for intervention. By contrast, the German-language guideline explicitly recommends against administering antenatal corticosteroids to asymptomatic women with a short cervix, negative biomarkers and a very low risk of delivery within seven days 12 . If corticosteroids are administered prophylactically too early or without a reliable likelihood of delivery in the short term, the birth will often occur outside the optimal therapeutic window or ultimately at term; the anticipated neonatal benefit is then not realised, while the mother and foetus are exposed to a pharmacologically potent treatment. Even in the late preterm birth range, the risk-benefit assessment is not merely an extrapolation of the evidence from earlier gestational ages: In the ALPS study, betamethasone did indeed reduce respiratory complications, but at the same time increased the rate of neonatal hypoglycaemia 14 . Observational data on children who were born at term despite antenatal exposure to corticosteroids also suggest possible associations with subsequent neurocognitive and neurosensory abnormalities; however, these data do not allow any conclusions to be drawn regarding causality 15 . A non-dogmatic approach to obstetrics therefore does not mean withholding a highly effective treatment, but rather applying it only when strictly indicated, timing its administration optimally, and considering repeat administration only following an updated clinical risk assessment.

Shoulder dystocia: Problems of definition, illusion of prediction and emergency competence

Shoulder dystocia is a rare but feared obstetric complication. It lends itself particularly well to analysing dogmatic patterns because prevention, definition, documentation and emergency management are closely intertwined. The current German-language S2k guideline emphasises the standardisation of the procedure for managing shoulder dystocia, whilst at the same time highlighting that the condition and its complications cannot be completely prevented or controlled, even with good care 16 .

The main problem is the expectation that shoulder dystocia can be reliably predicted. Macrosomia, maternal diabetes, obesity, prolonged labour and operative vaginal delivery are risk factors, but their predictive value is limited 16 17 ; in 50–75 per cent of cases of shoulder dystocia, no typical risk factors are present, and 28–49 per cent of all cases of shoulder dystocia occur in children with a birth weight of less than 4000 g 18 . A large proportion of cases of shoulder dystocia therefore occur in babies without extremely high birth weights. Conversely, liberal indications for caesarean section based solely on estimated foetal weight would expose many women to surgery without providing reliable and proportionate prevention of all cases of shoulder dystocia 16 .

The definition is not straightforward either. The incidence, documentation and forensic assessment vary depending on whether shoulder dystocia is defined by the failure of the body to be delivered following the delivery of the head, by the need for additional manoeuvres, by a specific interval between the delivery of the head and the body, or by the occurrence of foetal injuries. A practice that is not overly dogmatic accepts this lack of clarity, documents the clinical course precisely and focuses on mastering standardised manoeuvres through regular simulation training 16 .

Timing of cord clamping and the compromised newborn: when standard recommendations are challenged by pathophysiology

The timing of cord clamping is an example of changing obstetric practice. In full-term newborns, delayed cord clamping improves haemoglobin and iron status in particular 19 . In preterm infants, it is associated with significant neonatal benefits, including in terms of circulatory adaptation and the need for blood transfusions 20 . ACOG recommends delayed cord clamping for viable preterm and full-term infants for at least 30 to 60 seconds 21 .

The situation regarding compromised, full-term newborns remains controversial 22 . Traditionally, many algorithms favour immediate cord clamping to transport the child to the resuscitation area. From a pathophysiological point of view, this is not necessarily plausible in every situation. In cases of shoulder dystocia, tight umbilical cord entanglement or breech presentation, relative hypovolaemia in the newborn may be a factor. Case reports on resuscitation following shoulder dystocia have clearly articulated this hypothesis 23 .

This does not mean that immediate cord clamping is inherently wrong. The evidence base regarding compromised newborns is varied, and the practical implementation of resuscitation while the umbilical cord is still intact requires specific spatial, technical and staffing requirements. It would, however, be dogmatic to consider the matter settled. The very infants who may derive the greatest haemodynamic benefit are often those in whom established procedures are most likely to prevent placental transfusion. There is a need for relevant research and implementation in this area.

Patient autonomy, informed consent and forensic reality

Obstetrics is particularly challenging from an ethical perspective, as it requires the simultaneous consideration of maternal autonomy, foetal welfare, the doctor’s duty of care and time-critical emergency decisions. International ethical statements emphasise that the pregnant woman must not be reduced to a means of achieving foetal outcomes (e.g. the risk of intrauterine foetal death as pregnancy progresses versus, from the patient’s perspective, unnecessary shortening of the pregnancy); she remains the autonomous decision-maker 24 .

In clinical practice, conflicts arise in particular in connection with urgent decisions to perform caesarean sections, operative vaginal deliveries, episiotomies, the Kristeller manoeuvre, blood transfusions, refusal to consent to medical interventions or requests for specific birthing positions. For operative vaginal deliveries, the current German-language S2k guideline sets out the requirements regarding the determination of indications, information and informed consent, choice of instrument, procedure, documentation, legal aspects, debriefing, as well as training and simulation 25 .

In emergency situations, the line between advice, urgency, pressure and coercion can become blurred 24 25 . Empirical and legal studies on autonomy, disrespectful treatment and obstetric violence show that not only the medical outcome, but also the nature of communication and the pregnant woman’s involvement are central to the birth experience 26 27 28 .

As a general rule, the patient’s informed consent must be obtained prior to any medical procedure; for such statement of consent to be valid, the patient must have been provided with appropriate information 29 . In the absence of valid informed consent, a physical procedure may constitute assault under criminal law 30 . Irrespective of this, the principle of cost-effectiveness laid down in Section 12 of Book V of the Social Code (SGB V) requires that services must be adequate, appropriate and cost-effective 31 . These standards do not provide a simple decision-making framework or algorithm. They highlight an area of tension in which medical indications, patient information, documentation and appropriateness must be considered together.

An obstetrics practice that is free from dogma therefore avoids two extremes: paternalistic intervention against the woman’s express wishes, on the one hand, and the confusion of autonomy with a withdrawal from medical responsibility, on the other. Shared decision-making does not mean handing over responsibility. It means making the indications, alternatives, risks and preferences as transparent as the clinical situation allows 2 3 24 26 .

Psychological dogmas: Birth experience, guilt and the norm of the ‘right’ way to give birth

Dogmas exert their influence not only through interventions, but also through language and cultural expectations. The notion of a ‘right’ way to give birth can place a considerable burden on women. Vaginal birth may appear to be morally superior; caesarean section, a supposedly easier option, is not without a ‘moral’ demand on the pregnant woman stemming from her inability to give birth vaginally; breastfeeding is seen as an indispensable duty; immediate bonding is regarded as proof of successful motherhood; and so on. Such narratives are medically simplistic and psychologically risky.

The evidence on continuous support during labour shows that the support provided and the relationship with the obstetric team can influence relevant obstetric and subjective outcomes 32 . Conversely, a lack of respect, poor communication or the feeling of being at the mercy of others’ decisions can contribute to distressing or traumatic birth experiences 27 33 .

These relationships are being investigated in the German healthcare context as part of the prospective RESPECT project 34 . What is crucial, therefore, is not the moral assessment of the mode of delivery, but the quality of the medical indication, the care provided, communication and the debriefing.

A caesarean section may be medically necessary, a source of psychological relief or an expression of an informed preference; however, it may also be experienced as a loss. A vaginal birth can be empowering, but it can also be traumatic. Breastfeeding can be beneficial to health, but it must not become a moral test. Scientific obstetrics must recognise such ambivalences rather than regulating them through normative concepts.

Cultural sensitivity and stereotypes

In obstetrics, cultural sensitivity is frequently constrained to migration, language or religion. That is too narrow a view. Every patient brings with her own cultural, biographical and social background: Concepts of pain, control, shame, family, authority, technology, naturalness and risk. Academic background, professional socialisation, past experiences of violence, body image or the influence of the media may also be more relevant to decision-making than ethnic origin or religion.

Cultural sensitivity becomes dogmatic when it turns into stereotypes. Assumptions about mode of delivery, pain tolerance or risk-taking behaviour based on external characteristics are clinically unreliable. A patient-centred approach does not mean ignoring all differences, but rather exploring them with an open mind. The key question is: What exactly do safety, autonomy and a ‘good’ birth mean for this woman in her individual circumstances?

Innovation and digitalisation: beyond the dichotomy of technology versus nature

Another dogma in obstetrics is the contrast between technology and natural birth. It fails to recognise that technology in obstetrics is neither humanising nor alienating in and of itself. The key factors are which problem it solves, how it is implemented, who bears responsibility, and whether it is explained clearly to the pregnant woman and actually takes the pressure off obstetric teams.

Digital documentation, telemonitoring, structured self-monitoring of blood pressure, diabetes apps, PROMs (patient-reported outcome measures) and PREMs (patient-reported experience measures), AI-supported pattern recognition and digital aftercare can help to improve care, provided their clinical benefit has been demonstrated and their use is clinically appropriate.

PROMs and PREMs extend quality measurement beyond traditional indicators and can, amongst other things, assess mental health, bonding, breastfeeding, incontinence, satisfaction and the subjective experience of childbirth 35 36 37 .

At the same time, the risks associated with this are very real: data protection, false alarms, experiences of surveillance, the pathologisation of physiological pregnancies, digital inequality, diffusion of responsibility and algorithmic bias. Innovation must therefore not be treated as a new dogma. It requires evaluation, clear lines of responsibility, data security, clinical endpoints and a common understanding of which form of care is to be improved.

Particularly against the backdrop of a shortage of midwives, regional service bottlenecks and increasing documentation requirements, digitalisation can be a useful addition. However, it does not replace interpersonal relationships, clinical examinations or a well-coordinated obstetric team. Its value lies in directing attention more effectively, structuring communication and making the quality of care more measurable.

Out-of-hospital birth, centralisation and the discourse on risk

The debate surrounding out-of-hospital birth and centralisation is another area in which dogmatic positions tend to emerge quickly. On the one hand, there is the assumption that giving birth in hospital is, in principle, the only responsible option. On the other hand, there is occasionally the perception that out-of-hospital birth is, by its very nature, more autonomous, more natural and involves fewer medical interventions. Both positions oversimplify a complex healthcare issue.

The safety of out-of-hospital births depends largely on risk assessment, staff qualifications, documentation, transfer times, integration into regional networks and emergency communication. Critical views on planned home births emphasise the professional responsibility to take even rare, serious complications into account when providing advice 38 .

Appropriate risk selection and reliably integrated referral and escalation procedures are crucial to the safety of midwife-led models 4 39 .

An Austrian registry analysis shows that the transfer of births that began outside a hospital setting can lead to poorer maternal and neonatal outcomes, thereby underlining the importance of clear transfer procedures and effective cross-sectoral collaboration 39 .

This non-dogmatic approach is therefore not ‘hospital or out-of-hospital’, but rather: which women, with what level of risk, are being cared for where, by whom, with what potential for escalation, and with what level of transparency? Centralisation can improve safety when expertise and resources are pooled. However, it can also undermine accessibility, continuity and the birth experience if journeys become longer, facilities more impersonal and care more fragmented.

Hierarchy, team culture and organisational learning

Dogmas persist within organisations. They are reinforced by hierarchies, economic pressures, training practices and informal sanctions. In obstetrics, the phrase ‘that’s how we’ve always done it’ is not only a linguistic nuisance, but also a safety risk. It prevents new evidence, observations made by junior staff, or feedback from patients from being taken seriously.

Interprofessional collaboration in the delivery theatre requires more than just a friendly attitude. It requires clearly defined roles, mutual respect, standardised communication and the opportunity to escalate concerns without having to fear disciplinary action from superiors. A qualitative study on interprofessional collaboration in the delivery theatre shows that communication, collaboration and the respective organisational culture have a significant influence on interactions between midwives and doctors 40 and can therefore be key components of the safety of care.

In practical terms, this means: regular simulation training sessions, structured debriefings following emergencies, morbidity and mortality conferences, audit cycles, transparent discussions on indications, and a leadership culture that views dissent as a valuable resource. An obstetrics practice with few dogmas is not primarily a matter of individual brilliance, but of organisational learning capacity 16 25 .

Redefining quality: from process metrics to relevant endpoints

Traditional obstetric quality indicators often focus on easily measurable process and outcome data: Caesarean section rate, operative vaginal births, blood loss, perineal tears, neonatal pH, admission to the neonatal unit. These metrics are important, but they are incomplete. A low intervention rate does not automatically equate to good obstetric care if necessary interventions are delayed. A low caesarean rate is not a measure in itself if it is achieved through an inadequate acceptance of risk. Conversely, a high intervention rate does not automatically mean good safety.

The quality of obstetric care should therefore be understood in a multidimensional way: long-term pelvic floor function, breastfeeding, mental health, autonomy in decision-making, communication, continuity of care, access to the obstetric care of their choice, perceived equity in the distribution of resources, and the subjective experience of childbirth.

PROMs and PREMs can systematically assess, in particular, mental health, bonding, breastfeeding, incontinence, satisfaction and the subjective experience of childbirth 35 36 37 .

However, this gives rise to a new risk: Quality indicators, too, can be treated as dogma and misused to further one’s own interests. If key performance indicators are assessed without context, they create misguided incentives. A clinic with a high proportion of complex referrals should not be compared with a low-risk facility without taking into account risk adjustment and the mandate to provide care.

The methodological limitations of obstetric quality indicators, particularly with regard to their evidence base, discriminatory power and adjustability, have long been the subject of debate ( Table 2 ) 41 .

Table 2 Questions to consider for less dogmatic decision-making in obstetrics.

Dimension	Question	Implications for practice
Evidence	Which guideline or study supports the measure, and how strong is the evidence?	Making the level of recommendation and data quality transparent
Indication	What specific problem are we trying to solve now?	Distinguish routine practice from individual indication
Context	What resources, skills and escalation options are available?	Openly identify and assess local feasibility
Benefit–risk analysis	What desirable and undesirable consequences are plausible?	Communicate the absolute risks and uncertainties associated with the available evidence
Autonomy	Having been given appropriate information, what is the patient’s preference?	Document shared decision-making
Team	Have roles, responsibilities and concerns been clarified?	Use closed-loop communication and debriefing
Evaluation	How can we determine whether the routine is beneficial or harmful?	Establish audits, PROMs/PREMs and case discussions

Implementation framework for less dogmatic obstetric care

A pragmatic implementation framework can be derived from the analysis. Firstly, routines should be reviewed regularly to assess whether they are indicated. Every obstetric unit should be aware of which measures are actually standard practice, which are merely a matter of habit, and which are deliberately tailored to the level of risk.

Secondly, guidelines must be adapted to the local context. A recommendation is only effective if responsibilities, documentation, training, spatial requirements and escalation procedures are defined at the place of birth. This applies in particular to intermittent auscultation, delayed cord clamping in specific situations, the management of shoulder dystocia and digital monitoring approaches.

Thirdly, communication should be regarded as a core aspect of obstetrics. Counselling, informed consent, debriefing and team communication are not soft factors, but safety-critical processes. Fourthly, quality data must be put into context. Metrics that are not risk-adjusted and do not take the patient’s perspective into account can lead to misguided decisions.

Fifthly, innovation needs a clinical purpose. Not every app, not every dashboard and not every AI application improves healthcare. Conversely, rejecting digital solutions on the grounds of ‘naturalness’ is not a scientific argument. The key factors are benefits, safety, accountability and acceptance.

Limitations of the analysis

This paper is not a systematic review. It therefore cannot provide quantitative effect estimates and does not claim to offer a comprehensive account of all relevant dogmas in obstetrics. The selection of examples is deliberately clinical and discursive; it is intended to highlight typical mechanisms, not to present a definitive taxonomy.

A further limitation is that many of the issues discussed are highly dependent on the healthcare system in question. Recommendations on foetal monitoring, induction of labour, out-of-hospital births or digitalisation cannot be readily transmitted across different countries, hospital levels and funding models. That is precisely why contextualisation is a central part of the argument.

Conclusions

Dogmas in obstetrics are frequently rigid standards. They arise from an understandable desire for safety, predictability and reduced responsibility, but can actually jeopardise these very objectives if they override evidence, context and patient preference. Modern obstetrics must therefore combine two seemingly contradictory approaches: consistent standardisation where it promotes safety, and judicious individualisation where rigid rules are detrimental.

The key task is not to downplay the guidelines, but to use them correctly. Guidelines provide guidance; they are not a substitute for clinical reasoning. Thresholds are aids, not truths. Routines are tools, not ends in themselves. Patient autonomy is not a hindrance, but rather an integral part of good medical care.

An obstetrics practice free from dogma is evidence-based, team-oriented, communicative, adaptable and open to innovation. It questions every routine in terms of indication, evidence, plausibility, context, resources and informed patient preference. This does not make it any less safe, but rather more scientific, more transparent and more human.

Key takeaways

• Dogmas arise when sensible standards are upheld regardless of evidence, indications and context.

• Guidelines only improve care if they can be implemented locally, applied thoughtfully and are not misunderstood as rigid algorithms.

• Thresholds and time windows are clinical aids to decision-making, but must not obscure biological variability and measurement uncertainty.

• Patient autonomy, respectful communication and debriefing are key quality aspects of obstetric care.

• Digital innovation should neither be rejected on ideological grounds nor adopted uncritically, but should be assessed against patient-relevant outcomes.

How the article came about

This article is based on a lecture given by Holger Maul in February 2025 as part of the ‘Perinatology Aachen’ event, under the scientific direction of Werner Rath.

Funding Statement

No specific external funding was received for the preparation of this manuscript.

Für die Erstellung dieses Manuskripts wurde keine spezifische externe Förderung in Anspruch genommen.