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REVIEW: ACOG Committee Opinion on Approaches to Limit Intervention During Labor and Birth
| Posted on March 7, 2017 at 6:24 PM |
Note: all words in this piece that are in “quotation marks”
are excerpts or quotes from the ACOG Committee Opinion published February 2017. HERE is that article. The American College of Obstetrics and Gynecology just came
to a very important conclusion in THIS Committee Opinion that was published in
February 2017:  “Many common obstetric practices are of limited or uncertain
benefit for low-risk women in spontaneous labor. In addition, some women may
seek to reduce medical interventions during labor and delivery. Satisfaction
with one’s birth experience also is related to personal expectations, support
from caregivers, quality of the patient–caregiver relationship, and the
patient’s involvement in decision making (57). Therefore,
obstetrician–gynecologists and other obstetric care providers should be
familiar with and consider using low-interventional approaches, when
appropriate, for the intrapartum management of low-risk women in spontaneous
labor.”FINALLY. Yes, it is a little frustrating that it has taken years for
the doctors who manage pregnancy, labor and birth to acknowledge that less
intervention is best for birth outcomes.
However, I am grateful that ACOG has caught up with Dr. Bradley and all
the other proponents of dignity in birth that know “It’s not nice to fool
Mother Nature.” The part that interests me the most as a childbirth educator
is how they treat the topic of pain relief and coping techniques in labor. There is the acknowledgement that, “pharmacologic
methods mitigate pain, but they may not relieve anxiety or suffering. “ And
then this statement: “None of the nonpharmacologic techniques have been found to
adversely affect the woman, the fetus, or the progress of labor, but few have
been studied extensively enough to determine clear or relative effectiveness.” So there is finally the recognition that nonparmacologic
techniques do not adversely affect the woman, the fetus or the progress of
labor. And to CYA, they have to state that there is no conclusive study to
determine effectiveness. Be that as it
may, it doesn’t matter to me as a childbirth educator if a study can measure
the effectiveness. What I do know as an
educator and a doula is that if the mother perceives a pain coping practice as
effective, it is being effective for her in that moment. The key to continuing that pain coping practice hinges on two
questions: “Is the mother okay? Is the baby okay”” As long as both the mother
and the baby continue to tolerate the intensity of labor, then the conclusion effectively
says LEAVE THEM ALONE. In the article there are two distinctions between pain coping
practices: The pain coping practices that have been studied and, “have
all demonstrated statistically significant reductions in pain in many studies” Water immersion consistently has been found to lower pain
scores (8, 34). Intradermal sterile water injections Relaxation techniques Acupuncture Massage “Other techniques may help women cope with labor more than
directly affect pain scores” Childbirth education Transcutaneous electrical nerve stimulation [TENS] Aromatherapy Audioanalgesia Here are some more areas of discussion in the committee
opinion that bring obstetric care into the humane versus management for their
convenience. I have included the
corresponding bullet points from the summary and also provided some lay-person
translation as needed. Latent Labor: Labor
Management and the Timing of Admission ·
“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.” IN OTHER WORDS: If your baby is head-down when you start
labor, then your labor management can be individualized and include intermittent
fetal monitoring (freedom to move as labor indicates) instead of continuous
fetal monitoring (thus anchored to the bed) AND mother is free to try any
method of pain relief of non-drug pain relief that she would like to try. ·
“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.” IN
OTHER WORDS: If your labor has started and your bag of waters is intact, there
is no rush to admit you to the labor and delivery ward. If the mother is okay and the baby is okay,
phone contact and support from your care provider is the order of the day, and
the mother is free to continue with any non-drug pain coping practice that is
working for her. Term Premature Rupture of
Membranes ·
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. IN OTHER WORDS: If your bag of water breaks and you are not GBS-positive,
you as the patient can decline immediate induction and this committee opinion
instructs the care provider to support the patient in that choice. If you are informed, you also know this
includes declining vaginal exams that have the potential to introduce infection
and that water immersion is an available pain coping practice (see Henci Goer’s
Thinking Woman’s Guide to a Better Birth”). What bothers me a little is that if a woman is not
informed, it sounds like they are going to railroad her into the immediate
induction route. Yuck. As for women who are GBS-positive, the recommendation is
to admit the patient and start the administration of antibiotics. The committee says that the preference is for
immediate induction, but it doesn’t say one way or the other that it is the
best practice. You can go back to those
two important questions, “Is mom okay? Is baby okay?” If you get YES answers to
both of those questions, you may think about getting the antibiotics and then
postponing anything else that is offered until there is a medical indication “to
do something”. Continuous Support During
Labor ·
“Evidence
suggests that, in addition to regular nursing care, continuous one-to-one
emotional support is associated with improved outcomes for women in labor.” IN OTHER WORDS: LET
THE DOULAS IN THE ROOM!!! Routine Amniotomy ·
“For
women with normally progressing labor and no evidence of fetal compromise,
routine amniotomy need not be undertaken unless required to facilitate
monitoring.” IN OTHER WORDS: Amniotomy is the artificial breaking of
the bag of waters. You can read the info
sheet on this procedure HERE. What this committee opinion states clearly is
that THERE IS NO REASON to break the bag of waters if labor is progressing and
there is no evidence of fetal compromise.
Not to “help things along”. Not
to “speed labor”. Not “to see what
happens”. NONE. DO NOT break the bag of waters. The only reason stated for breaking the bag of waters is
in the case of the need of an internal fetal monitor. This monitor is screwed
into the baby’s fontanel, so in order to facilitate access to said fontanel, the
bag of waters needs to be out of the way. Intermittent Auscultation ·
“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.” IN OTHER WORDS: Get with the program and learn how to do
labor evaluation with a hand-held Doppler device. P.S.: Midwives have been doing this for
years. There are many risks associated with continuous fetal
monitoring – for more information I recommend you read THIS Cochrane review
that shows how a decrease in fetal monitoring increases positive birth
outcomes. There are many cases of false
positives with continuous fetal monitoring.
These false positives result in a more aggressive management of labor
that often leads to an increase in unnecessary cesarean birth outcomes. While there is a time and a place and much
gratitude for cesarean births that are needed, it is devastating for a mother
to read her operative report and realize that her cesarean birth could have
been avoided with a different approach to her care. Techniques for Coping With
Labor Pain ·
“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.” IN OTHER WORDS: Don’t push the epidural if the patient
wants to try some other things first. ·
“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.” IN
OTHER WORDS: Treat your patients as individuals!! What works for one does not
work for all. And pain is not the only
marker for labor management. As stated
in the committee opinion, “pharmacologic methods
mitigate pain, but they may not relieve anxiety or suffering.“ If the mother can handle the pain and is
doing something that does reduces anxiety or suffering, that is ok. It may be hard to watch, however, doing
nothing is fine as long as the mother and the baby are doing well. Hydration and Oral Intake in
Labor “Women in spontaneously progressing labor may
not require routine continuous infusion of intravenous fluids. Although safe,
intravenous hydration limits freedom of movement and may not be necessary.” IN OTHER WORDS: Routine use of IV fluids is
out!! Yeah!! The whole tone of this committee opinion is to treat patients as
individuals, so if there is no medical indication and the patient declines
routine IV, then leave her to labor without IV fluids. HERE is the summary of research presented at the Anesthesiology® 2015 Annual
Meeting. It states that, “most healthy women can skip
the fasting and, in fact, would benefit from eating a light meal during labor…improvements
in anesthesia care have made pain control during labor safer, reducing risks
related to eating”. Maternal Position During
Labor ·
“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.” IN OTHER WORDS: As long as labor is progressing and mom
and baby are well, let a mom labor in whatever position she deems useful. When it’s time to monitor the baby, any
position that allows for monitoring to happen is still acceptable. The easiest for
the nurse and the most uncomfortable position for the mother/baby is to have the
mother lie on her back (supine).
According to this committee opinion, other positions are now within
range of acceptable. Positions such as side
lying, hands and knees, or tailor sitting are all examples of other positions
that allow for fetal rotation and engagement in the pelvis while keeping the
mother still enough to undergo fetal monitoring. Second Stage of Labor:
Pushing Technique ·
“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.” IN OTHER WORDS: Don’t tell a woman how to push. If she follows her instincts, the baby will
come out. Valsalva pushing is when a
woman is directed to do forceful pushing during a contraction for a certain
count with no regard to what her body is doing physiologically. Physiological pushing allows for a woman to
work with her contractions: as she feels the peak, she will push as long as is
comfortable. End of story. Immediate Versus Delayed
Pushing for Nulliparous Women With Epidural Analgesia ·
“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.” IN OTHER WORDS: “Nulliparous” means a woman that has not
given birth before. Unless there is a
medical reason for the baby to be born as soon as possible, women, including
those who have epidural analgesia, are to be allowed a time period between the
time they are completely dilated (10 cm) and pushing. If the woman is monitored and both she and
baby are shown to be well, up to two hours can be allowed for the baby to
descend into a position that creates the urge to push, thus making the pushing
phase more effective. Sometimes the cervix is open and the baby is still high
in the pelvis, thus there is no urge to push.
When the pushing phase begins before there is an urge to push, this
effectively “starts the clock” by which a care provider or hospital policy may
deem it necessary to intervene with a vaginal operative birth (vacuum or
forceps delivery) or a cesarean birth. I hope this little review offers you the confidence as a consumer to advocate for what you know is right for you and your baby. Our inner wisdom about birth is present and powerful if we can allow it a voice in our labor space. Disclaimer:
Birthing From Within and Bradley
Method® natural childbirth classes offered in Arizona: convenient to Chandler,
Tempe, Ahwatukee, Gilbert, Mesa, Scottsdale
|
Categories: Acupuncture, Amniotomy, AROM, Artifical Rupture of Membranes, Augmentation
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