By Sharon Muza, BS, CD(DONA), BDT(DONA), LCCE, FACCE, LCE
March 2019 Update
ACOG revised their recommendations to include the support of family-centered cesareans and removed the recommendation for laboring down with an epidural. You can find more information about the updated 2019 Approaches to Limit Interventions During Labor and Birth recommendations in an updated post.
Hopefully, you have heard about the new Committee Opinion: Approaches to Limit Intervention During Labor and Birth put out last month by the American College of Obstetricians and Gynecologists and endorsed by the American College of Nurse-Midwives (ACNM) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). These newly released recommendations for reducing interventions in labor were initially covered on this blog last month by Adrianne Gordon in her post: ACOG Opinion: Limiting Interventions in Labor. In that piece, doulas, other birth professionals, and consumers had a chance to learn about the new recommendations for best practice aimed at reducing interventions.
Today on the DONA Doula Chronicles, I am going to discuss what I believe are the top six points from these new recommendations that birth doulas will want to be sharing with their clients during prenatal discussions and meetings. The entire committee opinion is outstanding and you may want to share it with your clients. It is not a highly technical read. Alternately, consider sharing this blog post, which helps explain some things in less technical terms. Making your clients aware of these new recommendations will help them to be prepared for care that follows this committee opinion. But more importantly, being informed can help them to ask for best practices and receive evidenced-based care and discuss their requests in advance of their labor.
I have added a checklist of these six recommendations to my prenatal forms so that I always remember to mention these topics. I have also saved the link to the Committee Opinion so I have easy access to it on the go.
Hospitals encourage laboring at home until active labor
In recent years, the definition of active labor has changed to reflect current research that active labor begins around six cm. That is not to say that hard work requiring significant coping doesn’t happen prior to six cm, but everyone understands that for healthy low-risk pregnant people, interventions are more likely to be avoided if they are admitted once they reach active labor. My clients need to be prepared for possibly doing a lot of laboring outside the hospital. Early labor can last 24 hours or more and that is very normal. I want them to be ready to do a lot of laboring at home. Certainly, I am happy to join them when they need me even in this early labor phase. But they need to understand that much of their labor will be occurring outside the hospital. This information needs to be shared during our prenatals so that we can have a plan for successfully laboring at home.
Active and expectant management of PROM are both equally good choices
For about ten percent of pregnant people, the membranes release prior to contractions or labor. This is called PROM which stands for premature rupture of membranes. Current best practice shows that the outcomes for both the pregnant parent and the newborn are the same (APGAR scores, cesarean rates, infection, etc) if families wait for 24 plus hours for labor (expectant management) or choose to get labor started with an induction shortly after the water breaks (active management). I want my clients to know that waiting is an option for them and that most people will go into labor within 24-48 hours. ACOG is now encouraging families to receive information and have the choice of waiting or getting things going medically. My clients will need to be prepared to make this decision if this is how their labor starts. Of course, if clients are GBS+, that is a different story and antibiotics are recommended to prevent GBS transmission to the baby and induction of labor may also be appropriate.
Intermittent fetal heart rate monitoring is appropriate for low-risk labors
How many labors can you think of where the client was asked to remain near or in the bed so the baby can be monitored and they remain tethered to the monitoring responders and wires? Think about how much time the L&D nurse spends adjusting the monitors over and over to “find the baby.” Evidence has shown for years that continuous fetal monitoring for low-risk labors does not improve outcomes yet many people are not given the option of intermittent auscultation during their labors. ACOG finally recognizes that intermittent monitoring is appropriate for many people and should be offered. I want my clients to know this and discuss this option in advance of labor with their doctor or midwife. Clients should be aware that continuous fetal monitoring for a low-risk labor can actually increase unnecessary interventions.
Artificial rupture of membranes in labor is not necessary
Most of my clients will experience their water breaking naturally sometime during their labor. A very few may be lucky enough to give birth to a baby born in the caul (membranes still intact) which historically has been considered to be good fortune for the child. ACOG now recognizes what research has demonstrated for years, that artificially breaking the water has little benefit to the labor and in fact may increase the risk of infection, cause a malpositioned baby and in a very small number of births, create an emergency from a prolapsed cord or placental abruption. Clients should understand that their membranes will release at the appropriate time and it is perfectly normal to labor with intact membranes and it is not necessary to have their doctor or midwife break them. Current research and the new committee opinion supports this.
Eat, drink and labor on!
In this recent committee opinion, ACOG has stated that drinking during labor is preferable to IV hydration. My clients can be prepared with lots of healthy beverages (coconut water, sports drinks, EmergenC, broths, juice) to consume during their labor. I encourage them to bring along their favorite sports water bottle to make drinking even easier. ACOG even alludes to the benefits of eating in labor, acknowledging that the risk of eating solid food in labor is almost non-existent and that in fact, eating can keep a person strong and energized. Clients should expect a saline or heparin lock, but for low-risk labors that are not medicated, there is no reason to be receiving IV fluids. A prenatal conversation in advance of labor can help my clients to stockpile healthy and appropriate food and beverages to promote their well-being and labor progress.
Labor down and push spontaneously with the urge to push
Most people do not benefit from being told to hold their breath and push to a count of ten during second stage. In fact, research shows that people will spontaneously push to a count of six when left alone to do it on their own. Letting breath out during the push through vocalizations or noises can be helpful, and pushing with the urge to push for as long as feels good helps the baby to stay oxygenated during this stage of labor. Additionally, being ten cm does not automatically mean that a person must start pushing. The uterus is a strong, amazing muscle and can do lots of work to move the baby down and into the birth canal without much pushing effort on the part of the laboring person. As the baby moves into the vagina, the urge to push will usually start to become more intense. That is a great time to start pushing! This is especially beneficial for people who have chosen to have an epidural. Clients will want to know that it can be normal to delay pushing until the baby moves down a bit lower and there is more of an urge to push. ACOG is recommending that people be permitted to push as they feel appropriate and that laboring down, especially with an epidural, offers many benefits.
Reducing labor and birth interventions is a good thing
As I mentioned above, this entire committee opinion is such a game-changer. These new recommendations to reduce interventions fall right in line with current evidence and are appropriate best practice. Birth doulas should be sharing these new recommendations with their clients so they understand what their options should and could be. This may bring up further discussion if low-risk clients find out that their healthcare provider is not open to these recommendations. You may need to offer more support as your clients determine what their options are at that point. I think that having these discussions with my clients will help them to be better prepared for their labor, have clear expectations about what their options are and offer some insight into what they should expect during their labor and birth.
Have you added these topics to your prenatal meetings? How have the conversations gone? How are you helping your clients to expect and receive evidenced-based care in line with these new recommendations? Are you already seeing these changes in the facilities that you work in? Everyone can benefit from sharing our experiences, so let us know how you are handling this in your practice. Let us know in the comments section.