The American College of Obstetricians & Gynecologists (ACOG) issued a new Committee Opinion: Approaches to Limit Intervention During Labor and Birth. This Opinion was endorsed by the The American College of Nurse–Midwives and the Association of Women’s Health, Obstetric and Neonatal Nurses which is a bit unusual and indicates the document supports normal birth. For more information on what a Committee Opinion is and summaries of other statements by ACOG, read our ACOG Updates for Doulas post.
The opening lines of the abstract gives a clear sense of the direction ACOG is going with this Opinion (and note the shout out to those who support patients!):
Obstetrician–gynecologists, in collaboration with midwives, nurses, patients, and those who support them in labor, 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.
That last sentence speaks strongly to what many doulas already know: many of the routine practices we see during labor are not rooted in evidence that demonstrates benefits to mother or baby. That ACOG is not only acknowledging this but leading with it should be applauded.
The Opinion ends with links to external resources for care providers including the Issue Brief from Choices in Childbirth entitled “Overdue: Medicaid and Private Insurance Coverage of Doula Care to Strengthen Maternal and Fetal Health” and the California Maternal Quality Care Collaborative’s Toolkit to Support Vaginal Birth and Reduce Primary Cesareans which includes doulas as one of the methods listed.
Interventions Addressed in ACOG Opinion
The document covers a significant list of common interventions in labor. In some cases the recommendations represent a shift toward a more hands-off approach (purple pushing) and for others, ACOG reaffirms their past positions (eating during labor).
- Automatic hospital admission for prelabor rupture of membranes
- Management of early (latent) labor
- Routine infusion of IV fluids
- Continuous fetal monitoring
- Routine amniotomy (breaking the water)
- Eating & drinking in labor
- Positioning
- Valsalva pushing (purple pushing)
- Water immersion during labor
- Laboring down (described as a rest period of 1-2 hours before pushing)
Continuous Support
Although doulas certainly would not describe labor support as an intervention per se, ACOG highlights its positive effects on outcomes for birthing women. Doulas are mentioned specifically and numerous citations are used to note the mounting evidence that continuous labor support is associated with:
- Shorter labors
- Less need for epidurals
- Fewer cesarean births
- Fewer operative deliveries (forceps or vacuum extraction)
- Higher 5 minutes Apgar scores
- Reduced cost of care
Given these benefits and the absence of demonstrable risk, patients, 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.
— Committee Opinion: Approaches to Limit Intervention During Labor and Birth, ACOG
Summary of Recommendations
Early labor – The latent phase of labor is generally defined as up to 4 cm dilation, but ACOG notes that active labor may not begin until 5-6cm for some women in this Opinion. For patients whose membranes are intact and both mother and baby’s status is reassuring, hospital admission is not necessary, the Opinion states. ACOG notes that early admission has been associated with increases in labor augmentation, cesarean births, internal monitors, and antibiotics. Reduced use of epidurals and greater satisfaction with the birth experience were also found. For women admitted to the hospital in the early phase of labor for pain or fatigue, ACOG suggests there may be benefits to offering water immersion and other nonpharmacological pain management, education, support, oral hydration, and position changes. These recommendations seems to support the informational, emotional, and physical support roles that doulas provide, particularly in early labor, and may help our clients feel confident with less medical management of early labor.
Prelabor Rupture of Membranes – The Opinion notes that most women with ruptured membranes will go into labor within 12 hours. Interestingly, the research summary in this summary notes that there is little difference in outcomes for expected management of PROM versus immediate induction. While higher admissions to Neonatal Intensive Care Units has been found with expectant management, the rate of neonatal infection was the same as in the induction group. The Opinion notes that hospital policy may be a factor in higher NICU rates, and that there may be little difference between expectant management and induction for term mothers with PROM. ACOG concludes that expectant management may be offered in cases where there is no need to expedite delivery. Given the overlap between expectant management and induction noted in the Opinion and the role of hospital policies, it is unlikely that doulas will see much, if any, change in how care providers address PROM in term pregnancies from this Opinion.
Intermittent Fetal Monitoring – The Opinion minces no words in this section stating that the widespread use of continuous electronic fetal monitoring (EFM) has not reduced perinatal death and cerebral palsy for low-risk pregnancies, yet has been associated with increases in both cesarean and instrumental vaginal birth. ACOG recommends intermittent auscultation using a hand-held Doppler for low-risk women who prefer it. The Opinion notes that the effect on the women’s labor experience and the demands on staff should be considered. Following the protocols and guidelines from the the American College of Nurse–Midwives (30), the National Institute for Health and Care Excellence and the Association of Women’s Health, Obstetric and Neonatal Nurses is suggested.
Pain Management – Use of a coping scale (“On a scale of 1 to 10, how well are you coping with labor right now?”) versus a pain level assessment is recommended to better help care providers come with a plan unique to the needs of each patient. ACOG notes that non-pharmacological pain management techniques have not been associated with risk to the mother, her baby, or the progression of labor, but there is little research on their effectiveness. The methods suggested in the Opinion that may assist women in coping with labor pain are broad and include acupuncture, massage, sterile water injections, music/white noise (audioanalgesia), childbirth education, transcutaneous electric nerve stimulation (TENS) and aromatherapy. Water immersion in the first stage of labor is mentioned due to the research associating it with lower pain scores.
Oral Intake in Labor – While this ACOG Opinion does not change the general approach seen in most hospitals to allow clear fluids but restrict food, it does note that current anesthesia techniques (meaning epidurals) are associated with a low incidence of aspiration – the primary driver for policies against eating during labor. IV fluids are not required, the Opinion notes, for patients whose labor is progressing and who were not induced.
Positioning in Labor – Despite referencing research which found that upright positions and movement were associated with a shorter first stage of labor, ACOG concludes in this section that care providers can support frequent position changes during labor so long as monitoring and treatments are not affected or contraindications are not present. If more hospitals adopt this Opinion’s recommendation for intermittent auscultation versus EFM, doulas may see greater support for a wider variety of positions during labor. This section mentions positioning during pushing but does not make a recommendation. Research that found upright or lateral positions were associated with fewer “abnormal” fetal heart rate patterns (quotation marks aded by ACOG), episiotomies, and operative vaginal births. Higher rates of tearing and increased bleeding were noted with upright or lateral positioning during pushing.
Pushing Technique – The Valsalva maneuver, known as purple pushing to many, is associated with a slightly shorter pushing phase (5 – 19 minutes depending on the study) and with higher rates of abnormal urodynamics such as urinary incontinence at three months postpartum. ACOG’s recommendation states that women should be encouraged to push in the way that she prefers and is most effective. This mention of effectiveness may result in care providers continuing to direct women to push by holding her breath while bearing down given the research which indicates a slightly shorter second stage with this technique.
Laboring Down with an Epidural – When contraindications are absent, women with epidurals can wait as long as 1-2 hours before pushing unless she has the urge to bear down sooner, the Opinion states. Doulas will find some interesting notes in this section including that most studies which look at the length of the second stage of labor and outcomes do not take into consideration that the second stage has two phases – the passive phase where the baby rotates and descends through the pelvis on its own and the active phase where the mother pushes. (And childbirth educators everywhere are quietly saying, “Duh!”) The Opinion also mentions that studies have found that the active pushing phase is reduced by approximately 20 minutes when a rest period to labor down is allowed. Significant increases the in the number of spontaneous vaginal births were found when patients were allowed to labor down.
Conclusion
Change occurs slowly in maternal medicine even with new guidelines or recommendations from a body like ACOG. While there are some encouraging suggestions in this Opinion, doulas are unlikely to see significant change to care practices or hospital policies as a result. The Opinion, does, however serve as a resource to educate our clients on the most recent position of ACOG including the research cited within it. Childbirth educators can also reference this document to encourage expectant families to ask questions and advocate for their preferences in regards to early labor management, comfort measures, monitoring, positioning and pushing.
— Adrianne Gordon, MBA, CD(DONA), Blog Manager