Recently, American Congress of Obstetricians & Gynecologists issued a new list of recommendations on ways care providers and hospitals can reduce unnecessary interventions in labor/birth. Today I'll list select parts that reinforce and affirm things we childbirth educators have been teaching for a number of years (italic text is from the ACOG report; bold emphasis mine).
- For a woman who is at term in spontaneous labor with a fetus in vertex presentation, labor management may be individualized (depending on maternal and fetal condition and risks) to include techniques such as intermittent auscultation and nonpharmacologic methods of pain relief
- Admission to labor and delivery may be delayed for women in the latent phase of labor when their status and their fetuses’ status are reassuring. The women can be offered frequent contact and support, as well as nonpharmacologic pain management measures
- When women are observed or admitted for pain or fatigue in latent labor, techniques such as education and support, oral hydration, positions of comfort, and nonpharmacologic pain management techniques such as massage or water immersion may be beneficial.
We have known for a long time that intermittent monitoring (auscultation) is wise for low-risk, healthy pregnant parents. This is because watching the baby too closely--i.e., continuous monitoring--all too often leads to unnecessary panic, when the heart rate variabilities we're seeing on the monitor are likely to be this particular baby's normal. Yet many hospitals and OB/GYN practices default to continuous monitoring; this is becoming even more common as more hospitals invest in wireless units.
We also know that, for low-risk pregnant parents, laboring out of hospital (mostly, at home) for early labor and often even into active labor tends to help labor progress in an optimal + healthy way. Watch for an upcoming blog post on the reasons it's ideal to labor at home for a long time--much longer than you might think--for your first labor/birth.
Non-pharmacologic methods of pain relief can be incredibly effective but are not something that most nurses/care providers are trained to suggest. These methods are things we go through in birth class; here's a sampling:
- movement/changing positions
- deep abdominal breathing
- vocalization ("intentional sound")
- hydrotherapy (bath/shower)
- massage & counterpressure techniques
- relaxation strategies such as relaxation exercises (done regularly prenatally; I give a set of them to each of my birth class students as suggested homework), lip trills, loose jaw, etc.
- finding a rhythm & ritual from one or more of the above
- a soothing, relaxing ambience (lighting, quiet, etc.) that promotes a natural boost of oxytocin, strengthening contractions and encouraging progress
Instead of offering non-pharmacologic pain relief options, most nurses or care providers offer the epidural by default. I hope that one positive change from this report will be that nursing schools adjust teaching to include non-pharmacologic strategies for pain relief, and hospitals encourage nurses to practice these suggestions. The two hindrances here are that 1) epidurals are a major income source for hospitals, and 2) nurses have plenty of duties already and they have little capacity to provide support in this way at this point in time, at least the way things are staffed in most hospitals. The latter brings me to another recommendation that complements this one...
ACOG says: Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support is associated with improved outcomes for women in labor.
Yes, this! This points to the value of labor support -- whether partner, family, friend and/or professional labor/doula support. Many OBs and even more midwives promote doula support; here's hoping this report will further that trend. This is particularly important in order for the previous recommendations to be more feasible.
ACOG says: Obstetrician–gynecologists and other obstetric care providers should inform pregnant women with term premature rupture of membrane (PROM [also known as prelabor rupture of membranes]) who are considering a period of expectant care of the potential risks associated with expectant management and the limitations of available data. For informed women, if concordant with their individual preferences and if there are no other maternal or fetal reasons to expedite delivery, the choice of expectant management for a period of time may be appropriately offered and supported. For women who are group B streptococci (GBS) positive, however, administration of antibiotics for GBS prophylaxis should not be delayed while awaiting labor. In such cases, many patients and obstetrician–gynecologists or other obstetric care providers may prefer immediate induction.
The point ACOG is making here is that many unnecessary inductions and cesareans result when hospitals set a fairly arbitrary deadline for birth once the woman's membranes rupture. In many hospitals, if a woman hasn't given birth within 24-36 hours after the water has broken, an OB will move to cesarean. Additionally, care provider is looking for the laborer needs to be in active labor within 18-24 hours of waters breaking. This means many care providers will start induction medications within a few hours after PROM if contractions haven't begun. This deadline is due to a small risk of infection, and is more often than not unnecessarily rigid.
Another thing to note is that laboring individuals are frequently checked in far earlier than necessary upon PROM, even in the absence of any concern (such as things like being GBS+, meconium in the fluid, or sign of infection). Along these lines, I appreciate that in the details of this report, ACOG states, "A woman with term PROM should be assessed, and the woman and her obstetrician–gynecologist or other obstetric care provider should make a plan for expectant management versus admission and induction." This means that if a pregnant parent would like to be assessed and then go home to wait for labor to begin, she should be allowed to do so. This needs to be an option more often than it currently is.
While I am pleased to see this inclusion to allow a laboring parent extra time and more of an expectant management approach and sending patients home to wait for labor contractions to begin, I do hope that further studies will be done to determine a more concrete time range for the choice to be patient, "for a period of time," as this phrase in ACOG's recommendation is too vague to effect concrete and beneficial change.
ACOG says: For women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring.
If care providers seem concerned with PROM causing infection to the baby, then why the routine amniotomy (artificially rupturing the membranes with a tool called an "amniohook")? I teach my expectant students that amniotomy is not recommended at all before at least active labor due to the aforementioned deadline to give birth. It normally wouldn't be suggested that early by most care providers, anyway. Once in active labor or beyond, it's really up to the laboring parent as to whether or not to agree to it should it be suggested. It can be one of the less aggressive/risky things to try if, for example, energy is low and as a way to expedite things in hopes of meeting baby sooner. There's no guarantee it will achieve this goal, but increases the likelihood. It also increases the possibility baby could show distress on the heart monitor as he/she loses the cushion and feels the contractions more strongly (as does laboring parent, often), and of course raises the relatively small risk of infection.
ACOG says: To facilitate the option of intermittent auscultation, obstetrician–gynecologists and other obstetric care providers and facilities should consider adopting protocols and training staff to use a hand-held Doppler device for low-risk women who desire such monitoring during labor.
Yes! The very first thing I recommend in birth classes on the monitoring topic is for students to ask if a hand-held Doppler is available. While it's not guaranteed to be available in all L&D units (it's more standard in birthing centers and home births), it's sometimes available upon request and is the least restrictive on laboring parent's movement. A nurse can come to wherever the laborer is instead of the laboring person having to come over to the bed/near the monitor.
ACOG says: Use of the coping scale in conjunction with different nonpharmacologic and pharmacologic pain management techniques can help obstetrician–gynecologists and other obstetric care providers tailor interventions to best meet the needs of each woman.
Tailoring labor strategies to fit the individual? Who'da thunk?! Oops, got a little sassy. Seriously, though, this is smart. For example, instead of just assuming that a laboring person's loud vocalization means not coping well and offering the epidural (as happened to me in my first labor and happens regularly with doula clients), let's actually go over the coping scale as a way to determine what would truly be helpful for the individual instead of making a blanket generalized recommendation that might or might not be helpful.
ACOG says: Frequent position changes during labor to enhance maternal comfort and promote optimal fetal positioning can be supported as long as adopted positions allow appropriate maternal and fetal monitoring and treatments and are not contraindicated by maternal medical or obstetric complications.
More yes! Here's to hoping more care providers and nurses will be supportive of a low-risk laboring person's natural-born instinct to move around in labor to facilitate healthy progress. Baby has to rotate and descend through the pelvis, so regular movement is key to help this as well as to boost the laboring person's comfort.
ACOG says: When not coached to breathe in a specific way, women push with an open glottis. In consideration of the limited data regarding outcomes of spontaneous versus Valsalva pushing, each woman should be encouraged to use the technique that she prefers and is most effective for her.
Music to my ears. I have always taught that the laboring individual should tune into natural instincts--to experiment with positions and wait for the physiological, uncontrollable urge to push--and that our bodies will guide us. If that urge does not arise, then perhaps the coached/directed pushing--aka the "Valsalva maneuver", to which nurses are trained to default--might be more helpful. The Valsalva maneuver is also called "purple" pushing because women are directed to hold their breath for unnaturally long periods of time and bear down more strongly than they probably would instinctively. The physiological urge often is masked/suppressed when pain medications are in use. As it stands currently, though, I always need to point out in class that laboring individuals have the right to request to not have directed pushing if they don't find it helpful. Hopefully, as fewer women are coached to hold their breath for pushing, as a result, fewer babies will show distress on the heart monitor.
ACOG says: In the absence of an indication for expeditious delivery, women (particularly those who are nulliparous with epidural analgesia) may be offered a period of rest of 1–2 hours (unless the woman has an urge to bear down sooner) at the onset of the second stage of labor.
I mentioned this in the last point on the topic of the physiological urge to push, and always explain to my students that just because we reach "complete" -- meaning 10cm dilation (cervical openness) and 100% effacement (shortness of cervix/lip of cervix entirely out of the way of baby's head) -- does not mean there's suddenly a rush to push the baby out. Yet in hospitals, laboring people are most often encouraged to begin pushing once they reach full dilation/effacement. Instead, I encourage laboring people to 1) request to wait, if necessary, and 2) experiment with positions and, in an unmedicated birth, wait for the uncontrollable urge to push to start.
Cheers to ACOG on this and their other recent recommendation on delayed cord clamping. It's encouraging when the things we birth teachers & doulas are already teaching to expectant parents are reinforced and confirmed by the ruling authority over the U.S. maternal health medical professionals (i.e., OB/GYNs). I hope that, over time, this will lead to better philosophical alignment and teamwork and lead to more positive and healthy birth experiences for expectant parents and babies.
"Approaches to Limit Intervention During Labor and Birth" (ACOG)
Lamaze's 6 Healthy Birth Practices
"Allow Labor to Begin on Its Own & Avoid Interventions That Are Not Medically Necessary" (Birth Matters NYC)