On January 25, 2017, the American Congress of Obstetricians and Gynecologists (ACOG) released a new committee opinion: Approaches to Limit Intervention During Labor and Birth. I found this committee opinion to be a positive statement in support of safe and healthy birth. I haven't felt this hopeful about a statement from ACOG since the groundbreaking Safe Prevention of the Primary Cesarean Delivery released exactly three years ago next month. Judith Lothian covered that consensus statement for Science & Sensibility at the time, which you can read here.

The Approaches to Limit Intervention During Labor and Birth committee opinion has been endorsed by the American College of Nurse-Midwives (ACNM) and the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). In fact, Tekoa L. King, as a liaison for ACNM, collaborated with the ACOG committee members to produce this opinion.

The new committee opinion aligns with the six long established and evidence based Lamaze International Healthy Birth Practices. These six care practices are based on best practice and rely on the highest standards of research on the topic of labor and birth. The Healthy Birth Practices have been the foundation of the Lamaze organization for many years and have guided and informed families and educators on the practices that support healthy and safe birth. The recommendations and conclusions that ACOG outlines lines up beautifully with the Healthy Birth Practices. Do you think the committee members took a Lamaze childbirth education class? Compare below and see what you think.

Lamaze Healthy Birth Practice 1 - Let Labor Begin On Its Own

ACOG Recommendations:

• Obstetrician-gynecologists and other obstetric care providers should inform pregnant women with term premature rupture of membrane (PROM [also known as prelabor rupture of membranes]) who are considering a period of expectant care of the potential risks associated with expectant management and the limitations of available data. For informed women, if concordant with their individual preferences and if there are no other maternal or fetal reasons to expedite delivery, the choice of expectant management for a period of time may be appropriately offered and supported. For women who are group B streptococci (GBS) positive, however, administration of antibiotics for GBS prophylaxis should not be delayed while awaiting labor. In such cases, many patients and obstetrician-gynecologists or other obstetric care providers may prefer immediate induction.

Lamaze Healthy Birth Practice 2 - Walk, Move Around and Change Positions During Labor

ACOG Recommendations:

• 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.
• Observational studies of maternal position during labor have found that women spontaneously assume many different positions over the course of labor. There is little evidence that any one position is best. Moreover, although many have encouraged a supine position during labor, this position has known adverse effects, including supine hypotension and more frequent fetal heart rate decelerations. Therefore, for most women, no one position needs to be mandated nor proscribed.

Lamaze Healthy Birth Practice 3 - Bring a Loved One, Friend or Doula for Continuous Support

ACOG Recommendations:

• Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support is associated with improved outcomes for women in labor
• Benefits found in randomized trials include shortened labor, decreased need for analgesia, fewer operative deliveries, and fewer reports of dissatisfaction with the experience of labor
• Continuous labor support also may be cost effective given the associated lower cesarean rate. One analysis suggested that paying for such personnel might result in substantial cost savings annually. 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.

Lamaze Healthy Birth Practice 4 - Avoid Interventions That Are Not Medically Necessary

ACOG Recommendations:

• For a woman who is at term in spontaneous labor with a fetus in vertex presentation, labor management may be individualized (depending on maternal and fetal condition and risks) to include techniques such as intermittent auscultation and nonpharmacologic methods of pain relief.
• Admission to labor and delivery may be delayed for women in the latent phase of labor when their status and their fetuses' status are reassuring. The women can be offered frequent contact and support, as well as nonpharmacologic pain management measures.
• When women are observed or admitted for pain or fatigue in latent labor, techniques such as education and support, oral hydration, positions of comfort, and nonpharmacologic pain management techniques such as massage or water immersion may be beneficial.
• For women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring.
• To facilitate the option of intermittent auscultation, obstetrician-gynecologists and other obstetric 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.
• Use of the coping scale in conjunction with different nonpharmacologic and pharmacologic pain management techniques can help obstetrician-gynecologists and other obstetric care providers tailor interventions to best meet the needs of each woman.
• The onset of active labor for many women may not occur until 5-6 cm. These data suggest that expectant management is reasonable for women at 4-6 cm dilatation who are in latent labor if maternal and fetal status are reassuring
• Most women can be offered a variety of nonpharmacologic techniques
• Oral hydration can be encouraged to meet hydration and caloric needs...Current guidance supports oral intake of moderate amounts of clear liquids by women in labor who do not have complications. However, particulate-containing fluids and solid food should be avoided. These restrictions have recently been questioned, citing the low incidence of aspiration with current obstetric anesthesia techniques. This information may inform ongoing review of recommendations regarding oral intake during labor.

Lamaze Healthy Birth Practice 5 - Avoid Giving Birth on Your Back and Follow Your Body's Urges to Push

ACOG Recommendations:

• 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, each woman should be encouraged to use the technique that she prefers and is most effective for her.
• In the absence of an indication for expeditious delivery, women (particularly those who are nulliparous with epidural analgesia) 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.

Lamaze Healthy Birth Practice 6 - Keep Mother and Baby Together, It's Best for Mother, Baby and Breastfeeding

ACOG Recommendations:

ACOG did not address this topic in the just released committee opinion.

I strongly suggest that you refer to the entire committee opinion which is fairly straightforward and relatively easy to read for the evidence that ACOG is relying on to support these new recommendations and conclusions.

ACOG acknowledges that avoiding interventions improves maternal and newborn outcomes and increases patient satisfaction. They state that "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."

I was delighted to see that ACOG also included and recognized the benefits of a quality childbirth education course for expectant families. ACOG stated "Other techniques, such as childbirth education, transcutaneous electrical nerve stimulation, aromatherapy, or audioanalgesia, may help women cope with labor more than directly affect pain scores..."

I expect to be highlighting more about this new ACOG committee opinion in future blog posts but strongly encourage you to click over to the ACOG site and read it for yourself. Would you please come back and share your thoughts after reading it? I am very interested in your opinion. ACOG, I look forward to more opportunities for our organizations to be in agreement as we both work toward helping families achieve a safe and healthy birth.

Published: January 27, 2017

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