The American Congress of Obstetricians and Gynecologists (ACOG) released a Committee Opinion recognizing the importance of patient satisfaction. The abstract acknowledges that many current obstetric practices do not benefit low-risk women in spontaneous labor.
Until recently the past several decades have seen OB-GYN doctors take over the birth experience for mothers. In 2011 there was a report 5.9% incident rate in episiotomies, which is a 3-fold increase from a report taken in 2000 in which the rate was 1.8%. In addition, laboring mothers also experienced more incidences of assisted deliveries such as vacuum-assisted deliveries which have a higher rate in the southern United States (20% to 25%) than in the northern states (5%). The rise of C-Sections has also occurred over the past decade. Routines such as these are often found to be most beneficial to mothers and many claim that they are used before it is completely necessary and before other laboring methods are employed.
In addition, women have been pressured to labor in a traditional manner, especially when in the hospital. Lying on their backs with their feet in stirrups, women are asked to bear down to through contractions. However, many experts agree that this is not the most effective way to labor during childbirth. The recommendations provided by the ACOG, as outlined below, note that women should be allowed to labor in different and varying positions so as to progress through labor naturally and more efficiently, and to delay the use of an epidural until a woman is fully in active labor so she can easily move through transitional labor.
The Committee Opinion, titled Approaches to Limit Intervention During Labor and Birth, was endorsed by the American College of Nurse Midwives and the Association of Women’s Health, Obstetric and Neonatal Nurses. Many of the recommendations imply the inclusion of the patient and supporters for decisions about the care provided to them. Here are the eleven recommendations outlined:
1. For low-risk women with a baby in a head-down position at full term, labor management can be individualized. This could include intermittent monitoring and non-pharmacological comfort techniques.
This is innovative because not only does it encourage care providers to inform mothers of options for labor management aside from pharmaceuticals, it implies that providers and staff should be knowledgeable about other measures for managing labor.
2. Healthy, low-risk women should not be admitted to Labor and Delivery until Active Labor.
Active labor was recently redefined to be 6 cm rather than 4 cm, so mothers who expect to be admitted earlier may be surprised that they are turned away in Early Labor. This means couples will need to have coping skills to get them to the point of admission. The recommendation also suggests mothers be provided frequent contact and support, so care providers who adhere to this recommendation could implement significant changes in their practices.
3. Women in early labor can benefit from many nonpharmacological forms of support including education and support, oral hydration, changing positions, massage and water immersion.
This is recognizing not only the benefit of delaying interventions, but also of using movement for as long as possible. There is overwhelming evidence for moving and using various positions to encourage good fetal positioning during labor and there are numerous position options. This recommendation could change the labor experience for many mothers.
4. If a woman has prolonged rupture of membranes, full-term mothers should be informed about the risks and benefits of induction and the option of waiting for labor to start. If Group B Strep is present, antibiotics should be administered even if labor is delayed.
ACOG recognizes that most women will go into labor spontaneously within 24 hours of their water breaking and that waiting, in some cases, may be a better or preferred option. The recommendation is fairly vague, as no specific time frame is suggested and will obviously vary greatly from provider to provider. It is important to note that once the bag of waters is broken, vaginal exams should be limited to reduce the risk of infection.
5. Outcomes improve when women have one-to-one emotional support in addition to regular nursing care.
This means ACOG is referencing the undeniable benefits of doula support. This could actually potentially lead to hospitals hiring doulas as part of the staff, making them available to more laboring women. This is huge!
6. If labor is progressing normally and there is no evidence of fetal distress, there is no benefit to breaking the bag of waters.
This guideline nods to the possibility of risks if the water is broken unnecessarily such as: putting women on a set clock to deliver, increasing the intensity of labor without the buoyancy of water and increasing the risk of infection.
7. Staff should be trained and prepared to offer low-risk women intermittent monitoring with the hand-held Doppler instead of continuous monitoring.
Evidence shows that constant monitoring does not improve outcomes for moms and babies. ACOG is recognizing the benefits of allowing mothers to move freely during labor without the restrictions of the Electronic Fetal Monitor and encouraging care providers to facilitate that with intermittent monitoring.
8. Along with pain medication, women should be informed about other coping mechanisms and care providers can tailor interventions to meet the needs of each patient.
This is discouraging “conveyor belt” type care and encouraging providers to offer various forms of support to meet the needs of each individual.
9. Frequent position changes promote maternal comfort and optimal fetal positioning and should be supported as long as a mother and baby can still receive monitoring or other necessary treatment.
This further promotes the need for movement in labor, as do several of these guidelines. As long as a mom is intermittently monitored, she should be able to get into any birthing position she feels is comfortable and that encourages progress.
10. Laboring women should be encouraged to use techniques to push that she prefers and that are most effective for her.
ACOG is recognizing noisy pushing is more effective than “purple pushing”- pushing while holding the breath at the instruction of the staff. This recommendation shows a significant shift in control, especially over this stage of labor.
11. If there is no medical reason to expedite labor, woman should be offered a period of rest for 1-2 hours at the onset of the Pushing stage of labor, especially if she has an epidural.
ACOG is encouraging providers to give moms the rest they need for this exhausting part of labor. This is commonly known as “laboring down” and can give mothers and babies the time they need to work through the Pushing stage together.
One other recommendation acknowledges that not all women in labor require continuous IV fluids. They still recommend women in labor avoid solid foods, but note that this policy is being questioned and will be under ongoing review. This comes after the press release from the American Society of Anesthesiologists suggested women in labor would benefit from eating during labor.
The Importance of Mother-Friendly Care During Labor and Delivery
Overall, I’d say these opinions show an encouraging shift in the obstetric field towards more evidence-based practices and mother-friendly care. Research has shown that a mother’s birth experience can play a significant role in the mother’s mental state immediately following the birth, or even months or years after their child’s birth. For some mothers, a traumatic birth experience can put a mother more at risk for postpartum depression. Some mothers may even experience post-traumatic stress disorder from a traumatic birth experience.
Working toward a more mother-friendly birthing environment will allow mothers to have control over their own birthing experience. Birth is a highly personal event, and many mothers want to experience labor and delivery in a way that is best for them. And although things don’t always go to plan, a mother-friendly environment can help to create a more positive atmosphere for the mom-to-be and her new child.
The Effects of a Traumatic Birth Experience
The women experience traumatic births can experience strong repercussions as a result of the birth. These feelings include:
- Feelings of not being a “good mother”
- Feelings of failure
- Post-traumatic stress disorder
- Sleeping issues like insomnia
- Postpartum depression
Research has also found that mothers who have a traumatic birth experience may also change their reproductive behavior in that they will not have additional children or be apprehensive to adding more children to their family
There is still work to be done, but as the risks of interventions are recognized, more families will be able to explore all of their options for maternity care, and care providers will have to offer more individualized care. Both mothers and babies will be able to have a more positive birth experience, resulting in better postpartum mental states for mothers and a better environment for babies to thrive.