Approaches for Ob-gyns and Maternity Care Providers to Limit Intervention During Labor and Birth in Low-Risk Pregnancies
January 25, 2017
Washington, DC –For low-risk pregnancies, obstetrician-gynecologists and other maternity care providers should consider labor and delivery approaches that facilitate limited medical intervention, according to new guidance released today by The American College of Obstetricians and Gynecologists (ACOG).
The Committee Opinion, endorsed by both the American College of Nurse-Midwives (ACNM) and the Association of Women’s Health, Obstetric and Neonatal Nurses, includes several recommendations to help ob-gyns, midwives, nurses, and patients work together to meet each woman’s goals for labor and birth.
“Practitioners always put the best interests of moms and babies at the forefront of all their medical decision-making, but in many cases those interests will be served with only limited intervention or use of technology,” said Committee Opinion author, Jeffrey L. Ecker, M.D., chief of the Obstetrics & Gynecology department at Massachusetts General Hospital. “These new recommendations offer providers an opportunity to reexamine the necessity of obstetric practices that may have uncertain benefit among low-risk women. When appropriate, providers are encouraged to consider using low-intervention approaches that have been associated with healthy outcomes and may increase a woman’s satisfaction with her birth experience.”
What constitutes “low-risk” will vary depending on a laboring woman’s condition and medical circumstances but generally involves a clinical scenario in which a woman presents at term in spontaneous labor and has had an uncomplicated course of prenatal care. For such women in the early stages of labor with reassuring maternal and fetal status, patients and providers may consider delayed hospital admission until approximately five to six centimeters dilated. Also, for women who are progressing normally and do not require internal fetal monitoring, it may not be necessary to rupture the amniotic sac. In the case where a woman at term experiences premature rupture of membranes, patients and providers may consider planning a short period of expectant management before undertaking labor induction if there are no maternal or fetal reasons to expedite delivery.
The recommendations also suggest that women benefit from continuous emotional support and the use of non-pharmacologic methods to manage pain. Support offered by trained labor coaches such as doulas has been associated with improved birth outcomes, including shortened labor and fewer operative deliveries. In addition to considering use of medications or epidural anesthesia to manage pain in labor, practitioners are encouraged to offer women coping techniques, such as massage, water immersion in the first stage of labor, or relaxation techniques. Recognizing that the complete absence and elimination of pain is not what all women value, use of a coping scale rather than pain scale is recommended to evaluate the multifactorial experience of labor.
“Techniques such as an epidural can relieve pain but may not ease anxiety or suffering,” said Tekoa L. King, CNM, MPH, ACNM liaison committee member and lead author. “Providing emotional support and coping mechanisms have proven positive outcomes, therefore, it’s recommended that providers consider instituting policies that allow for the integration of support personnel in the labor experience. This strategy may be beneficial for patients and cost effective for hospitals due to an association with lower cesarean rates. It is important that midwives, ob-gyns and other care providers collaborate to support women both emotionally and physically over the course of labor.”
Other recommendations for low-risk pregnancies include the option of intermittent instead of continuous use of fetal heart rate monitoring when appropriate; frequent labor position changes for increased comfort and optimal positioning of the baby; and encouraging women to use their own preferred pushing technique.
The Committee Opinion, “Approaches to Limit Intervention During Labor and Birth,” #687, will be available in the February 2017 issue of Obstetrics and Gynecology.
The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 58,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org