We all could use a little good news, right? After decades of skyrocketing c-section rates and increasing interventions upon interventions, this trend in US obstetrics is miraculously reversing. The American College of Obstetrics and Gynocologists (ACOG) and other professional groups have put out some excellent recommendations over the past couple of years. Not coincidentally, they are recommending practices that we midwives have never left and have always done because, well, it's common sense and they work.
WIN #1: Hands off the low-risk mom
1) In January 2017, ACOG published a committee opinion piece recommending a "hands off" approach to managing low risk births. This is a victory for women and their partners who have been saying for decades they just want to be left in peace to give birth to their babies.
What does "hands off" mean to ACOG?
- Artificial rupture of membranes a.k.a. "breaking of waters" is not necessary in normal progressing births
- Active labor starts at 6cm instead of 4cm. They cited studies showing lower rates of epidurals and need for pitocin.
- If your water breaks, it's best to wait for labor instead of automatically being checked in to the hospital and induced.
- IVs should not be required or routine.
- An end to forced pushing or "purple/Valsalva" pushing.
- Using intermittent instead of continuous fetal monitoring.
- Allowing a "laboring down" or resting phase for 1-2 hours before pushing.
- Allowing position changes during labor and pushing as long as it doesn't interfere with monitoring.
WIN #2 : Encourage one-on-one & emotional support in labor
There was a time when US hospitals banned any labor support at all. Not even the father of the baby could be present. Women were held hostage and often treated very poorly with no support, witnesses or recourse. Only after nurses and mothers in the 1958 wrote an anonymous article in Ladies Home Journal about the "Cruelty in Maternity Wards" did people take notice.
First, the Lamaze and Bradley revolution of the 70s-80s got the fathers in the labor room doing support. The 90's brought in the professional doula movement. A cascade of studies and data have proven the efficacy of continuous labor support. Doctors, nurses and hospitals are not always friendly to doulas despite their importance to women and their efficacy and insurance coverage for doulas is extremely rare. This landmark recommendation may change that.
Facts cited in the report:
- doula care saves money for consumers and government
- c-section rate is 40% lower in births with doula care
- linked to shortened labor
- decrease need for pain medication
- families report higher satisfaction with their labor
WIN #3: Delay the cord clamping
In December 2016, ACOG took a good look at delayed cord clamping. Thankfully, ACOG is now recommending ending the practice in healthy, vigorous infants. And yes, it can be done even in c-section deliveries.
While "delayed cord clamping" may be framed as a "new" practice that has health benefits, we might also consider prematurely clamping of cords is harmful. Immediate cord clamping is a harmful practice with no physiologic or medical benefit. Babies that have their cords clamped immediately lose a significant amount of stem cells, iron rich blood cells, immune factors and reduced overall blood volume with effects similar to suffering a hemorrhage. Three cheers for ending this antiquated, bad habit!
WIN #4: It's okay to eat in labor.
In 2015, the American Society of Anesthesiologists said it's okay to "let" women eat in labor. Since the beginning of hospital birthing, women have been banned from eating during labor citing the risk of aspiration in case a woman needed to be "put under" general anesthesia. The result has been millions of women doing the hardest physical endurance task of their lives fueled only on ice chips. It took decades to amass the data showing that the harms of starving women overshadow the remote possibility that she may need general anesthesia. Finally, they have come around to say most women would benefit from a light meal during labor. They have even found that in some cases, aspirating stomach juices is harmful if you haven't been eating because they are more acidic and caustic on your lung tissues. Ew.
In the real world, what does this mean? Am I going to automatically get a "hands off" birth?
Does this mean that my doctor won't touch the cord, will let me eat and I won't have to get induced if my water breaks? Yes and no. Of all the various fields in the US medical system, obstetrics is known for being the slowest to change. 80% of US obstetric practices are not based on high level evidence. It takes an average of 11 years for practices to change after new evidence comes out. Sad, but true.
Doulas of North America published this somber but realistic commentary on the new guidelines:
Change occurs slowly in maternal medicine even with new guidelines or recommendations from a body like ACOG. While there are some encouraging suggestions in this Opinion, doulas are unlikely to see significant change to care practices or hospital policies as a result. The Opinion, does, however serve as a resource to educate our clients on the most recent position of ACOG including the research cited within it. Childbirth educators can also reference this document to encourage expectant families to ask questions and advocate for their preferences in regards to early labor management, comfort measures, monitoring, positioning and pushing.
— Adrianne Gordon, MBA, CD(DONA), Blog Manager
The good news is that if your hospital and doctor are not up with these recommendations, you now have good support to ask for what you want in labor. This is how change is made. It's how we got the dads into the labor room, how we got rid of the routine shaving and enemas as well as drastically reduced episiotomies in this country. Be assertive, be persistent, and bring robust labor support.
Or......you could just hire a midwife.
Midwives have always encouraged women eat in labor.
Midwives have always left the cord alone.
Midwives have always given one-on-one emotional support.
Midwives have always been "hands off" the low risk mother.
Hands off and common sense practices are staple in the Midwives Model of Care. Midwives have been doing these things correctly for generations. You won't have to fight for the care you want. It's good news that more of the things that make midwifery care great will be available for hospital/MD patients. But it's even better news that you can get this kind of care right now from your local midwife!
*CAVEAT EMPTOR: Not all midwives practice the Midwives Model of Care or evidence based care. Most midwives that are employed and supervised by physicians and work in hospital are limited by hospital regulation and obliged to work under medical model protocols, not midwifery based protocols. Keep this in mind when hiring a provider. You will have the most flexibility if you hire an independent midwife with hospital privileges, or in a free standing birth center or at home. Also, remember, all of the these recommendations are for low risk women only!