ACOG Encouraging Limited Interventions
What the ACOG opinion about interventions means for mothers and babies
It is important that care for mothers and babies during labor and birth reflects the most up-to-date evidence, especially when it comes to deciding when and how to use medical interventions. In February 2017, the American College of Obstetrics and Gynecology (ACOG) issued a new committee opinion about how interventions should and should not be used during labor. These recommendations, if consistently put into practice by care providers, will have wide-ranging benefits and lead to positive outcomes and positive birth experiences for many women and their babies.
Recognizing that a growing number of women and their care providers are seeking to limit unnecessary interventions during labor, ACOG states that “many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor,” which is something that many doulas, childbirth educators and care providers have seen time and again firsthand.
These are their new recommendations, in easy-to-understand terms, and what they mean for care during labor and birth:
- A mother who goes into labor on her own at full-term should be given individualized care, including intermittent fetal monitoring (rather than continuous) and non-medicinal pain relief, such as massage or movement.
This means the mother should be actively involved in making decisions about her care, including monitoring and pain management.
- If a mother and baby are healthy, they do not need to be admitted to the hospital during early labor. In this case, the care providers should offer the mother support and suggest pain management methods that don’t involve drugs.
This means that healthy mothers with typical pregnancies can labor safely at home and should be given counsel from their care providers without being admitted. The committee cites studies that show women admitted during early labor have a higher rate of cesarean births.
- Something to drink, a massage or a bath to soak in should be offered to mothers feeling pain or fatigue during labor. In addition, the mother should receive education and support during this time.
This means that drugs don’t have to be the first response to a tired or uncomfortable mom. She should be given options, kept hydrated, and supported.
- When a mother’s water breaks, her care providers should discuss her individual situation and options with her, including the option to wait for labor to begin on its own (expectant management). For women who are group B streptococci (GBS) positive, however, administration of antibiotics should not be delayed while waiting for labor to begin. In such cases, many patients and physicians/midwives may prefer immediate induction.
This means that just because a mother’s water has broken, her labor doesn’t necessarily need to be started or augmented with medication in order to birth the baby quickly. The care provider should discuss a woman’s particular situation with her when deciding how to proceed. The exception noted here is that the committee recommends that antibiotics be given immediately if the mother has tested positive for Group B Strep.
- Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support is associated with improved outcomes for women in labor.
This means that a consistent support person – whether it be a partner, doula, family member or friend – is helpful, effective and encouraged.
- If a woman is laboring, progressing and her baby or babies are showing no distress, routine amniotomy need not be undertaken unless required to monitor the baby.
This means that a woman’s water does not need to be broken by a care provider to progress labor.
- To make intermittent fetal monitoring a practical option, care providers 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.
Low-risk mothers don’t need continuous fetal monitoring. The care providers and staff should be trained to use Doppler monitors to check the baby’s heart rate intermittently during labor.
- Use of the coping scale in conjunction with different pain management techniques can help care providers tailor interventions to best meet the needs of each woman.
This means that helping a mother identify her level and area of discomfort can help a care provider tailor management strategies to her needs. This doesn’t have to include pain medication.
- 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.
This means that not only will a mother be more comfortable if she moves around during labor, but doing so will also help the baby get into position for birth.
- When not coached to breathe in a specific way, women push with an open glottis. In consideration of the limited data regarding outcomes of spontaneous versus Valsalva pushing (which is being told to take a deep breath, hold it, then push), each woman should be encouraged to use the technique that she prefers and is most effective for her.
There’s no need for women to hold their breath or breathe in a certain pattern while pushing. She should do whatever is most comfortable and effective for her.
- If there’s no emergency situation, women (particularly those who are first-time moms with an epidural) 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.
Mothers – especially those giving birth for the first time – should be given the option to rest before pushing, unless there are signs of distress or other mitigating factors.
In conclusion, the committee determined that “obstetrician–gynecologists and other obstetric care providers should be familiar with and consider using low-interventional approaches, when appropriate, for the intrapartum management of low-risk women in spontaneous labor.” Evidence demonstrates that outcomes improve when a mother is informed, given choices and supported during labor -- and this applies to pain management and interventions, as well. Current common practice doesn’t necessarily reflect what evidence shows us are the best practices, but this committee opinion is a big step in the right direction toward improving care for mothers and babies.
Jennifer Stutzman, Freelance Writer
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