In Labor and Birth Care

Abstract: Obstetrician-gynecologists . . . can help women meet their goals for labor and birth by using techniques that are associated with minimal interventions and high rates of patient satisfaction. Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor. . . . Obstetrician-gynecologists . . . should be familiar with and consider using low-intervention approaches for the intrapartum [during labor] management of low-risk women in spontaneous labor.

Science & Sensibility’s recent post shows how ACOG’s latest Committee Opinion, “Approaches to limit intervention during labor and birth,” aligns with Lamaze’s “Six Healthy Birth Practices.” As you can see from the excerpt of the Opinion’s abstract above, the Opinion officially admits that the routine use of medical intervention is undesirable, that low-intervention approaches have merit, and that care should be individualized, a statement that amounts to an endorsement of optimal care, that is, the least use of medical intervention that produces the best outcomes given the individual case. On the one hand, this is nothing short of revolutionary for ACOG. On the other, a closer read reveals just how much the Opinion hedges ACOG’s bets: “Uncertain” benefit, as opposed to “no” benefit? “Consider” using, as opposed to “should be” using? “Help women meet their goals,” as opposed to “practice evidence-based care”? Let’s see how this tension between optimal care recommendations and “sort of” plays out.

Limiting Medical Intervention

. . . consider using low-intervention approaches for the intrapartum management of low-risk women in spontaneous labor.

The recommendation to limit medical intervention applies only to “low-risk women in spontaneous labor.” Considering that approaching half of women will be induced (Zhang 2010), nearly one-third of the remainder will have labor augmented (Declercq 2013), and that some women aren’t low-risk, the percentage of “low-risk women in spontaneous labor” will be no more than a small fraction of all laboring women, which means the injunction, as weak as it is, will hardly ever apply.

Refraining from Hospital Admission in Early Labor

For women who are in latent labor and are not admitted, a process of shared decision making is recommended to create a plan for self-care activities and coping techniques. An agreed-upon time for reassessment should be determined at the time of each contact. Care for women in latent labor may be facilitated by having an alternate unit where women can rest and be offered support techniques. . . . 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.

No quarrel there, which brings me to another point: notice as you follow along that recommendations are much more straightforward and unequivocal when they don’t affect obstetric practice.

Term Pre-Labor Rupture of Membranes (PROM)

Obstetrician-gynecologists . . . should inform pregnant women with term PROM who are considering a period of expectant care of the potential risks associated with expectant management and the limitations of available data. . . . [I]f 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.

The Opinion notes that 77-79% of women will begin labor spontaneously within 12 hr and 95% within 24-28 hr and quotes the Cochrane systematic review (Dare 2006): “Since planned [immediate induction] and expectant management may not be very different, women need to have appropriate information to make informed choices.” Despite this, the Opinion concludes with this minimal support of expectant management. It’s a rare woman who would opt to wait once her doctor told her there were risks—which, by the way, does NOT constitute sufficient information to make an informed choice—along with the “limitations of available data.” Moreover, the narrative omits that if fingers and monitoring leads are kept out of the vagina, duration of ruptured membranes is much less of an issue (Olsen 2010; Rouse 1994; Soper 1996).

The Opinion adds that Group B strep preventive treatment shouldn’t be delayed while awaiting labor, which makes sense, but if you think about it, delaying induction in GBS women would be preferable because it would ensure that all antibiotic doses could be administered before the birth whereas that might not be the case if induction was immediate and the labor took off.

Continuous Support During Labor

It . . . may be effective to teach labor-support techniques to a friend or family member. . . . Obstetrician-gynecologists and other obstetric care providers and health care organizations may want to develop programs and policies to integrate trained support personnel into the intrapartum care environment to provide continuous one-to-one emotional support to women undergoing labor.

Citing the Cochrane review on the subject (Hodnett 2013), the Opinion touts the benefits of continuous one-to-one emotional support, including fewer cesareans. It mentions doulas as providers and, as you can see, suggests that it may be effective to teach a relative or friend labor support techniques. (Memo to ACOG: It’s called “childbirth education,” and it’s been around for coming up on 60 years.) However, the Opinion overlooks that that same review found that the statistically significant reduction (meaning unlikely to be due to chance) in cesareans disappeared when the support person was a staff member or a member of the woman’s social circle and when epidurals were available and continuous fetal monitoring (cardiotocography) was routine. About this the Cochrane reviewers write:’

[The results that availability of epidural analgesia and use of continuous fetal monitoring eliminate the effect of continuous support on the cesarean rate] raise questions about the ability of labour support to act as a buffer against adverse aspects of routine medical interventions. . . . Effects of continuous labour support appear to vary by provider characteristics. Divided loyalties, additional duties besides labour support, self-selection and the constraints of institutional policies and routine practices may all have played a role in the apparently limited effectiveness of members of the hospital staff. . . . Furthermore, . . . the support of partners and others with whom they have a longstanding relationship is qualitatively different and more complex than that of a woman who is experienced and often trained to provide labour support and who has no other role than to provide it.

In other words, the Opinion recommendations are unlikely to have any effect.

Routinely Rupturing Membranes

These data suggest that for women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring.

For one thing, the Cochrane review the Opinion cites not only found no benefits for electively rupturing membranes but rather a probable increase in cesareans (Smyth 2013). For another, women in normally progressing labor with no evidence of fetal compromise don’t need internal monitoring. In fact, they don’t need continuous monitoring at all, which takes us to the next recommendation . . .

Intermittent Listening

To facilitate the option of intermittent [listening], obstetrician-gynecologists . . . 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.

The Society of Obstetricians & Gynaecologists of Canada’s official position reads (Liston 2007): “Intermittent auscultation is the recommended fetal surveillance method during labor for healthy women without risk factors for adverse perinatal outcome,” and the U.K.’s Royal College of Obstetricians & Gynaecologists’ policy states (NCCWCH 2014): “Do not perform cardiotocography for low-risk women in established labour.” Shame on ACOG for their weasel wording. Furthermore, it’s up to women to request it? Also, medical staff don’t already know how to use the hand-held device? Seriously? Not that it matters much since few women would fall in the low-risk category anyway by ACOG’s definition.

Techniques for Coping with Labor Pain

Multiple nonpharmacologic and pharmacologic techniques can be used to help women cope with labor pain. These techniques can be used sequentially or in combination.

The Opinion offers the rationale that non-drug techniques haven’t been found to have adverse effects on women, babies, or labor progress. What the Opinion leaves out, though, is that regional anesthesia and opioids do, which makes non-drug strategies the superior first-line option if women are willing to try them. Oddly, the Opinion states that “few have been studied extensively enough to determine clear or relative effectiveness,” right before citing research finding that water immersion, sterile water injections, relaxation techniques, acupuncture, and massage have been demonstrated to reduce pain and that childbirth education, transcutaneous electrical nerve stimulation, aromatherapy, and audioanalgesia may help women cope with labor, although not affect pain directly.

Of great interest, the Opinion suggests using a labor coping scale (“On a scale of 1-10, how well are you coping with labor right now?”) instead of a pain measurement scale, which would be a big step in the right direction if it were used to recommend something other than epidurals or opioids to women who felt they weren’t coping adequately and were open to the idea.

Hydration and Oral Intake in Labor

Women in spontaneously progressing labor may not require routine continuous infusion of intravenous fluids, . . . Current guidance supports oral intake of moderate amounts of clear liquids by women in labor who do not have complications. However, particulate-containing fluids and solid food should be avoided.

There isn’t a shred of evidence that routine IVs have any benefits, and as with all medical interventions, they have harms, one of which is listed: interference with mobility. Granted, approving oral intake beyond sips of water or ice chips is good news, but the continuing prohibition of thicker liquids and solid food is disappointing. The Opinion backs the prohibition solely with references to ACOG’s and the American Society of Anesthesiologist’s guidelines, not to any research evidence, probably because there isn’t any. The Opinion acknowledges this in a roundabout way: “These restrictions have recently been questioned, citing the low incidence of aspiration with current obstetric anesthesia techniques,” and opens the door a crack: “This information may inform ongoing review of recommendations regarding oral intake during labor.” This is further than they have gone before; still, between induction, epidurals, and augmentation, few women would be free of IVs or considered eligible for oral intake.

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.

Not exactly a ringing endorsement, but it’s a start.

Pushing Technique

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.

The systematic review they cite found no benefits for coaching women to bear down forcefully with a closed throat (Valsalva pushing) (Prins 2011), and, as the Opinion notes in the discussion of this recommendation, there is some evidence that coached pushing weakens the pelvic floor.

Immediate Vs. Delayed Pushing for 1st-Time Mothers with Epidural Analgesia

Collectively, these data suggest that 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.

The Opinion’s discussion includes an analysis of the same two studies evaluated in CBU’s recent blog post on the topic and expanded on in a Science & Sensibility post and comes to the same conclusion.

Is the Glass Half Empty or Half Full?

On the one hand, ACOG’s admission that common obstetric practices are “of limited or uncertain benefit” and there might be better ways of doing things is little short of jaw dropping as is that the committee producing this Opinion had a liaison member from the American College of Nurse-Midwives at the table. On the other hand, the recommendations didn’t go nearly as far as they should, considering that we have a body of evidence-based knowledge regarding best practices that goes back decades, and, one presumes, “liaison” meant the midwife wasn’t allowed a vote. Then, too, it’s frustrating to think how many more women would fall into the “low-risk, spontaneous labor” category were it not for conventional obstetric management. Still, this is probably the best that could be accomplished politically and given ACOG’s medical-model biases. All in all, it might be going too far to say a new day has dawned for U.S. obstetric practice, but between this Committee Opinion and “Safe Prevention of the Primary Cesarean Delivery,” the sun appears to be peeking above the horizon.

The Take-Away

Since nothing here would push an obstetrician not already inclined in that direction to practice optimal care, health permitting, your best bet is to find a good midwife. You may also wish to consider planning birth at a freestanding birth center or at home.

Update 4/3/17: Childbirth Connection has published “New Professional Recommendations to Limit Labor and Birth Interventions: What Pregnant Women Need to Know,” because, as they diplomatically put it: “Unfortunately, it often takes many years before health care providers reliably carry out the recommendations of professional organizations. So it is important for pregnant women themselves to become informed and take an active role in securing high-quality care for themselves and their babies.”

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